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THE    SENILE  HEART 


*s- 


^><mL 


THE  SENILE  HEART 


Its   Symptoms,  Sequels,  and   Treatment 


BY 

GEORGE  WILLIAM  BALFOUR,  M.D.  (St.  And.) 

LL.D.  (Ed.),  F.R.C.P.E.,  E.R.S.E. 

Consulting  Physician  to  the  Eoyal  Infikmaey,  to  the  Eoyal  Hospital 
FOE  Sick  Children,  and  to  the  Eoyal  Public  Dispensary, 
Edinburgh  ;  Consulting  Physician  to  Leith  Hospital, 
formerly  Physician  to  Chalmers  Hospital, 
Edinburgh,  etc.  ;  Member  of  the  Uni- 
versity Court  of  St.  Andrews 


Nascentes  morimur,  Jinisque  ah  origine  pendet 

—  Manilius,  Astronomicon,  iv.  16 


MACMILLAN    AND    CO. 

AND    LONDON 

1894 

All  rights  reserved 


Copyright,  1894, 
By  MACMILLAN   AND    CO. 


^^  Ofe>M      ^ 


Nortoooti  IPrcss : 

J.  S.  Gushing  &  Co.  —  Berwick  &  Smith. 

Boston,  Mass.,  U.S.A. 


PEEFACE 


Disease  often  deranges  the  mechanism  of  the 
cardiac  valves,  and  thus  places  an  actual  or  con- 
structive obstacle  in  the  way  of  the  onward  flow 
of  the  blood.  To  maintain  the  circulation  under 
these  conditions  the  myocardium  must  hypertro- 
phy—  the  heart  necessarily  enlarges.  This  we  all 
know.  But  few  realize  that  the  loss  of  elasticity, 
and  other  changes  which  the  arterial  system  under- 
goes, during  our  progress  from  youth  to  age,  also 
cause  a  hindrance  to  the  onward  flow  of  the  blood 
which  has  to  be  compensated  in  a  similar  manner. 
In  late  life,  and  without  any  history  of  previous 
disease,  the  heart  is  often  found  to  be  enlarged, 
and  this  enlargement  is  under  these  circumstances 
said  to  be  idiopathic.  But  enlargements  of  the 
heart  form  no  exceptions  to  the  universal  law 
that  there  is  no  effect  without  an  antecedent  cause. 

Owing  to  the  changes  in  the   vascular   system 


vi  PREFACE 

just  referred  to,  no  heart  reaches  advanced  age 
without  some  degree  of  enlargement.  This  trifling 
enlargement  is  of  slow  growth,  gives  rise  to  no 
symptoms,  and  is  only  found  when  looked  for. 
But  when  after  middle  life  distressing  symptoms 
attract  attention  to  the  heart,  in  by  far  the  larger 
proportion  of  cases  there  is  discoverable  no  history 
of  any  antecedent  myocarditis  or  other  disease, 
but  the  symptoms  are  entirely  due  to  disturbance 
of  the  nutrition  or  of  the  innervation  of  the 
myocardium  interfering  with  and  modifying  the 
normal  senile  enlargement  of  the  heart. 

By  far  the  most  widespread  and  most  interest- 
ing varieties  of  cardiac  disease  are  to  be  found 
in  this  connection,  while  the  comfort  and  lon- 
gevity of  many  depend  upon  a  clear  understand- 
ing of  the  various  causes  which  contribute  to 
such  modifications  of  the  Senile  Heart,  and 
an  appropriate  treatment  of  the  many  distressing 
symptoms  so  often  associated  with  it. 

17  Walker  Street,  Edinburgh, 
February,  1894. 


CONTENTS 


Chapteb  Page 

I.       iNTKODrCTORT 1 

II.  How  THE  Heart  is  affected  by  Age        .         .21 

III.  Symptoms  and  Signs  of  the  Senile  Heart      .       35 

IV.  Palpitation,  Tremor  Cordis,  Tachycardia      .       63 
V.  Bradycardia,  and  Delirium  Cordis  ...      91 

VI.     Angina  Pectoris  .         .        .         .        .         .        .     115 

VII.     Concomitants    and    Sequels    of    the     Senile 

Heart.     Gout 157 

VIII.     Concomitants    and    Sequels    of    the     Senile 

Heart.     Glycosuria,  Gouty  Kidneys   .         .     187 

IX.     The     Therapeutics    of     the     Senile     Heart. 

Generalities    .        .         .         .         .         .        .214 

X.     The     Therapeutics     of     the     Senile     Heart. 

Exercise  and  Diet  .         .         .         .         .     234 

XI.  The  Therapeutics  of  the  Senile  Heart. 
Drugs  likely  to  be  Useful,  and  how  to 
USE  THEM  ........     258 

XII.     The    Prognosis  of   Special   Symptoms.     Eeca- 
pitulation     of     treatment     with    special 
Reference  to  Symptoms         ....     286 
vii 


ILLUSTRATIONS 


FiGUEE  Page 

1.  Innervation  of  Heart 38 

2.  Sphygmogram  op  Feeble  and  Irregular  Pulse  .  46 

3.  ■»  Sphtgmogram  op  Irregular  Pulses  in  Dilated 

4.  J  Hearts .         .49 

5.  Sphtgmogram  op  Tachtcardiac  Pulse          .         .  78 

6.  Sphtgmogram  op  Hemiststolic  Bradtcardia       .  106 

7.  Sphtgmogram  op  True  Bradtcardia     .         .        .  107 

8.  Ridged  Goutt  Nail 177 

9.  Furrowed  Nail 177 

10.  Heberden's  Knobs 179 

11.  Hatgarth's  Nodosities 181 

ix 


THE  SEI^ILE   HEART 


CHAPTER   I 

INTEODUCTOKY 

The  late  Sir  Robert  Christison,  in  his  first 
report  on  the  emerged  risks  of  the  Standard 
Assurance   Company,  stated  that  the   7,    ^,        , 

^      'J  '  Death  rarely 

statistics  he  was  dealing  with  seemed  due  to  age 
to  show  that  but  few  even  of  the  aged 
die  from  natural  decay,  but  "  mostly  from  some 
specific  disease,  just  like  younger  persons."  ^ 
And  he  also  said  that  the  term  "  gradual  decay," 
when  used  as  an  explanation  of  the  cause  of  death 
of  even  old  people,  was  "  little  else  than  an  admis- 
sion of  ignorance."  ^  It  is  consolatory  to  have 
such  high  authority  for  believing  that  at  the  most 
advanced  ages  death  is  not  due  to  age  alone,  but 
to  disease ;  because  we  always  personify  disease, 
we  feel  that  we  may  escape  it,  we  can  fight  it, 

1  Monthly  Journal  of  Medical  Science^  August,  1853,  p.  109. 

2  Op.  cit.,V'  110. 

1  B 


2  THE   SENILE  HEART 

and  often  overcome  it ;  but  age  is  the  "  carle 
dour"  to  whom  we  must  all  succumb.  Hence  a 
well-founded  belief  that  disease  and  not  age  has 
been  the  cause  of  death,  even  at  the  most  ad- 
vanced ages  hitherto  recorded,  is  fraught  with  the 
hope  that  science,  if  not  luck,  may  make  the 
patriarchal  ages  again  our  own,  and  that  the  man- 
tle of  Methuselah  may  yet  fall  upon  the  shoulders 
of  his  nineteenth  century  successors.  From  Sir 
Robert's  point  of  view  there  is  no  reason  to  regard 
this  as  impossible ;  it  even  looms  in  the  future  as 
vaguely  probable.  But  there  is  another  point 
from  which  the  lookout  is  not  quite  so  hopeful. 
Many  years  ago  an  old  writer  recorded 

Yet  as  man's      jijTj-         i  •  £  \  •      j.- 

life  is  limited  ^^^^  traditional  experience  or  his  time 
age  mvst  have  in  these  memorable  words  :  "  The  days 
an  impor  an     ^£  ^^^^^  years  are  threescore  years  and 

ten ;  and  if  by  reason  of  strength  they 
be  fourscore  years,  yet  is  their  strength  labour 
and  sorrow ;  for  it  is  soon  cut  off,  and  we  fly 
away."^  The  Psalmist  does  not  set  up  three- 
score and  ten  as  an  age  to  which  all  must  at- 
tain and  which  none  may  exceed,  but  merely 
states  it  as  the  average  limit  of  a  full  and 
complete  life  beyond  which  but  few  may  pass, 
and  that  only  "by  reason  of  strength,"  which 
soon  withereth  away. 

1  Tsalm  xc,  verse  10. 


INTRODUCTORY  ■  3 

And  to-day  the  same  story  is  repeated  in  the 
prosaic  pages  of  the  Registrar-General,  with  all 
the  emphatic  truthfulness  of  nineteenth  century 
statistics.  "  Of  100,000  born  in  this  country,  it 
has  been  ascertained  that  one-fourth  die  before 
they  reach  their  fifth  year;  and  one-half  before 
they  have  reached  their  fiftieth  year.  Eleven 
hundred  will  reach  their  ninetieth.  And  only  two 
persons  out  of  the  100,000  —  like  the  last  barks  of 
an  innumerable  convoy  —  will  reach  the  advanced 
and  helpless  age  of  one  hundred  and  five."  ^  Of 
the  many  millions  born,  only  isolated  exceptions 
attain  great  ages,  and  all  are  ultimately  entombed 
in  the  urns  and  sepulchres  of  mortality,  for  "  time 
like  an  overwhelming  flood  bears  all  his  sons 
away."  Tradition  and  statistics  are  thus  agreed 
that  few  of  those  born  attain  the  age  of  three- 
score and  ten,  and  that  beyond  that  age  they  die 
off  so  rapidly  that  seventy  years  may  be  prac- 
tically regarded  as  the  extreme  limit  of  even  a 
long  life. 

The  life  of  the  human  body  having  thus  an 
end  as  well  as  a  beginning,  it  may  be  identified 

1  The  above  quotation  will  be  found  at  p.  24  of  Smiles'  work 
on  Thrift.  London,  John  Murray,  1886.  It  is  based  on  the 
Life-tables  of  the  Eegistrar-General ;  one  of  the  latest  of  these 
makes  one-half  die  before  forty-seven.  Vide  Tsihle  B.,  p.  vii.. 
Supplement  to  Annual  Beport,  1885. 


4  THE   SENILE  HEART 

with  development,  and  all  its  phases  inseparably 
linked  with  structural  change.^ 
■X  ^l  ^^7  ^  We  are  so  much  accustomed  to  asso- 

with  develop- 
ment, and         ciate  development  with  growth  merely, 
consequen  y     ^j^^^   ^^   seems   a   somewliat    startling^ 

terminates  o 

necessarily       proposition  to  connect  it  also  with  de- 

and  naturally  ^  -l.    i.  £  £  ca    '      ^.^ 

in  death  ^^^'  ^  ^^  ^^'®  sumciently 

educated  to  regard  the  development  of 
the  body  as  naturally  ending  only  with  its  death.^ 
But  this  conception  of  the  nature  of  development 
involves  also  the  idea  that  as  there  are  develop- 
mental phenomena  initial  in  character,  so  there 
must  also  be  similar  phenomena  which  are  ter- 
minal. And  this  brings  with  it  matter  for  serious 
consideration  ;  for  with  it  comes  also  the  reflection 
that  terminal  phenomena  may  not  always  be  re- 
stricted to  that  advanced  age,  to  which  alone 
they  seem  to  be  appropriate.  For  just  as  we  may 
have  a  precocious  development,^  so  we  may  also 

1  "  Jede  Function  ist  an  mechanische  Veranderungen  der 
Substanz  gekniipft." — Virchow,  Vier  Beden  ilber  Leben  und 
Kranksein,  Berlin,  1863,  p.  96. 

2  "Development  and  Life  are,  strictly  speaking,  one  thing; 
though  we  are  accustomed  to  limit  the  former  to  the  progres- 
sive half  of  life,  and  to  speak  of  the  retrogressive  half  as  decay, 
considering  an  imaginary  resting-point  between  the  two  as  the 
adult  or  perfect  state."  —  Huxley,  British  and  Foreign  Medical 
Beview,  October,  1853,  p.  305. 

8  In  the  British  3Iedical  Journal  for  6th  February,  1886, 
p.  263,  mention  is  made  of  a  child  three  and  a  half  years  old 


INTROD  UCTOR  Y  5 

have  a  premature  decay.  The  development  of 
man,  in  the  only  true  sense  of  the  expression,  is 
a  physiological  process,  dependent  upon  tissue 
change  and  not  on  years,  and  it  may  attain  its 
natural  termination  before,  as  well  as  after,  the 
conventional  threescore  and  ten.  To  employ  the 
expression  "  gradual  decay  "  as  an  indication  that 
death   has   occurred   from   age    alone    may   often 

who  looked  like  a  boy  of  ten  or  twelve  years  of  age,  and  in 
whom  puberty  commenced  at  the  early  age  of  eighteen  months. 
Many  similar  cases  have  been  recorded  by  various  authors  from 
Seneca  and  Pliny  downwards.  Prematurity  of  development 
and  precocity  of  growth  are  essentially  distinct,  though  there 
is  a  close  bond  of  union  between  them.  Thus  females  not 
infrequently  menstruate  prematurely,  but  precocity  of  growth 
in  that  sex  is  so  rare  that  Geoffroy  Saint-Hilaire  has  only 
recorded  two  cases  of  combined  precocity  of  growth  and  pre- 
maturity of  development  among  females.  Among  males,  on 
the  other  hand,  many  such  cases  have  been  recorded,  and  in 
them  premature  development  of  the  genital  organs  is  almost 
invariably  associated  with  precocity  of  growth.  Some  of  the 
cases  recorded  have  been  very  remarkable.  Sauvages,  Hist,  de 
VAcad.  de  1666  a  1669,  t.  ii.,  p.  43,  has  given  full  particulars 
of  a  boy  of  six  who  was  five  feet  high  and  broad  in  proportion. 
His  growth  was  so  rapid  that  it  could  almost  be  seen  ;  he  had  a 
beard,  looked  like  a  man  of  thirty,  and  had  every  indication  of 
perfect  puberty.  He  had  a  full,  deep  bass  voice,  and  his  ex- 
traordinary strength  fitted  him  for  all  country  work.  At  five  he 
could  carry  any  distance  three  measures  of  rye  weighing  84 
pounds ;  and  at  six  years  and  a  few  months  he  could  easily 
carry  on  his  shoulders  burdens  weighing  150  pounds.  But  he 
did  not  become  a  giant  as  everybody  expected ;  he  soon  got 
feeble,  deformed,  and  almost  an  idiot.  Vide  Histoire  des 
Anomalies,  par  M.  Isidor  Geoffroy  Saint-Hilaire,  Paris,  1832, 
Vol.  i.,  p.  197,  etc.     Vide  also  note  1,  p.  12. 


6  THE   SENILE  HEART 

enough  be  little  else  than  "  an  admission  of  igno- 
rance," but  to  confound  terminal  phenomena  with 
disease  is  worse;  it  is  the  unconscious  revelation 
of  an  ignorance  which  is  not  admitted. 

The  superficial  observer,  who  fixes  his  attention 
upon  gradual  decay  alone,  sees  but  little  of  death 
from  age ;  but  he  who  recognizes  the  existence, 
the  nature,  and  the  importance  of  terminal  phe- 
nomena, not  only  sees  many  deaths  from  age,  but 
is  often  privileged  to  ward  off  for  long  the  ulti- 
mate and  inevitable  end.  The  linking  of  growth 
with  decay  as  part  of  the  development 

Obsta  princi-         n  j.  •!  •  •  j. 

piis  an  impor-  ^^  ^^n  opens  up  striking  views  as  to 
tant  aid  in        the  gradual  evolution  of  terminal  phe- 

prolonqing  , ,  /•   x  i        •  a. 

y.yg     '  nomena,  as  well  as  oi  the  importance 

of  the  early  recognition  of  their  first 
beginnings,  and  of  the  various  modes  in  which 
they  threaten  life.  Because  in  this  matter  per- 
turbative  medicine  and  heroic  measures  can  do  no 
good,  and  may  do  much  harm.  To  be  of  any  use 
at  all,  we  must  put  ourselves  in  nature's  place 
and  work   as   nature  works.^     Here    or   there  we 

1  Our  lives  are  but  a  bundle  of  consequences  ;  our  present  is 
but  the  outcome  of  our  past.  It  is  by  trifling  advantages, 
momentarily  minute  and  imperceptible,  that  nature  either 
worsens  or  improves  the  status  of  our  vitality,  and  it  is  by 
securing  these  trifling  advantages  and  turning  them  to  the  good 
of  our  patient  that  vital  declension  is  averted,  and  chronic  ail- 
ments remedied  when  that  is  possible.  Vide  Darwin,  Origin  of 
Species,  and  Balfour's  Introduction  to  the  Study  of  Medicine^ 
A.  «Sb  C.  Black,  1805,  p.  237. 


INTR  ODUCTOPY  7 

discover  some  trifling  failure,  which,  like  the 
"little  rift  within  the  lute,"  threatens  serious  dis- 
aster erelong;  but  appropriate  remedies,  timely 
applied,  and  long  persevered  with,  may  enable  us 
to  avert  this  disaster,  and  by  the  slow  accumula- 
tion of  petty  advantages  change  the  commence- 
ment of  decay  into  the  renewal  of  strength.  In 
this  way  we  shall  more  certainly  prolong  our  life, 
and  secure  comfort  in  existence,  than  by  the  un- 
guents, the  hot  baths,  and  the  elixir  vitae,  by  which 
our  forefathers  sought  to  emoUiate  the  rigidity  of 
age,  and  to  add  a  fresh  stock  of  vital  force  to  that 
which  was  fast  wearing  away.^ 

We   are   born  with  potentialities,  not  powers; 
we  have  no  store  of  energy  upon  which  to  draw, 
which  may  be  wasted,  and  which  must 
daily  diminish.     It  is  well  for  us  that  J Q^^Q^^jy 
it  is  so,  as  we  are  all  so  apt  to  squan- 

1  The  notion  that  desiccation  is  the  cause  of  age,  in  the 
obnoxious  sense  of  the  word,  was  widely  prevalent  in  early 
times.  It  gave  rise  to  the  story  of  the  rejuvenation  of  Pelias 
in  Medea's  caldron,  to  which  Lord  Bacon  refers  as  an  instance 
of  the  utility  of  warm  bathing  in  warding  off  age.  Desicca- 
tion as  a  cause  of  age  is  also  referred  to  by  Galen  in  his  treatise 
De  Sanitate  Tuendo  and  De  Marasmo ;  and  Haller  actually 
states  that  fishes  live  long  because  their  bones  are  soft  and 
cartilaginous.  Primos  Linece,  §  972.  Early  indications  of  all 
the  most  modern  ideas  of  preserving  vitality  by  drinking  hot 
fluids,  clothing  in  woollen  garments,  and  feeding  on  peptonized 
aliments,  are  to  be  found  in  Lord  Bacon's  Historia  Vitce  et 
Mortis^  Spalding's  edition,  London,  1858,  Vols.  ii.  and  v. 


8  THE   SENILE  HEART 

der  our  energy  in  work  or  play,  or  to  have  it 
wasted  for  us  by  disease,  that  had  we  only  a  fixed 
amount  on  which  to  draw,  but  few  of  us  would 
live  to  old  age,  and  not  so  many  as  now  even 
to  middle  life.  As  it  is,  all  our  energy  comes 
from  without ;  we  take  it  in  as  food  in  the  Poten- 
tial form,  and  we  transform  it  into  the  Kinetic 
form  by  means  of  the  oxygen  circulating  in  our 
blood.  Every  act  of  life,  every  pulse  that  beats 
within  us,  every  thought  we  think,  involves  this 
transformation  of  energy,  even  though  no  appar- 
ent movement  indicates  the  presence  of  voluntary 
life.  That  we  may  continue  to  live,  the  products 
of  this  chemical  action  must  be  removed,  and  the 
used-up  waste  replaced  by  fresh  oxidizable  mate- 
rial; and  our  organism  is  so  constructed  that  for 
a  time  this  goes  on  continuously.  The 
latest  definition  of  life  is  based  upon 
these  facts,  for  "the  continuous  adjustment  of 
internal  relations  to  external  relations  "  ^  is  obvi- 
ously but  a  concise  statement  of  the  conditions 
necessary  for  the  continuous  manifestation  of  liv- 
ing action,  and  not  a  definition  of  life  itself. 
Though  it  therefore  fails  the  metaphysician,  this 
definition  is  practically  sufficient  for  the  physician, 
who  deals  only  with  the  physics  involved.     And 

1  The  Principles  of  Biology,  by  Herbert  Spencer.     Williams 
and  Norgate,  London,  18G5,  Vol.  i.,  p.  80. 


INTRODUCTORY  9 

we  may  also  accept  the  converse,  that  death  is  the 
result  of   a  "  failure  to  balance   ordi- 

Death  defined. 
nary  external  actions  by  ordinary  in- 
ternal actions."  ^  But  food  and  oxygen  remaining 
plentiful,  as  we  may  assume  they  ordinarily  do, 
there  seems  no  reason  why  assimilation,  oxidation, 
and  the  genesis  of  force  should  not  go  on  forever, 
or  until  some  cataclysmic  change  in  our  environ- 
ment should  disturb  the  balance  of  internal  and 
external  actions.  It  is  within  ourselves,  therefore, 
that  we  must  seek  for  that  change  which  causes 
these  processes  of  assimilation,  oxidation,  and  the 
genesis  of  force,  gradually  to  fall  out  of  corre- 
spondence with  the  relations  between  oxygen  and 
food,  and  the  absorption  of  heat  by  the  environ- 
ment, which  happens  in  old  age,  and  is  the  cause 
of  death  by  natural  decay .^ 

In  days  gone  by  the  hypothesis  of  a  gradual 
decrease  of  vital  force  was  supposed  to  explain  the 
enigma  of  gradual  decay .^     But  vital 

£  .      r     ,  ,  1  i!       J.1,  Old  idea  of 

lorce  IS  but  another  name  lor  the  sum     .,  ,  . 

vital  force. 

of  all  the  vital  actions  of  the  frame ; 

and   to  point   out   that   these   are   decreasing   is, 

1  Spencer,  op.  cit.,  p.  89. 

2  Spencer,  op  cit.,  p.  88. 

3  "La  gene  de  I'influence  vital  s'accroit  sans  cesse."  —  Caba- 
nis.  "  That  considerable  differences  exist  in  the  stock  of  vitality 
originally  imparted  to  the  frame  in  different  individuals  cannot 
be  doubted,  some  being  destined  to  a  shorter,  and  others  to  a 


10  THE  SENILE  HEART 

indeed,  to  indicate  that  the  organism  is  dying,  but 
is  no  explanation  of  why  it  dies.  Failure  in  the 
genesis  of  force  is  only  an  indication  of  failure  in 
oxidation  or  assimilation. 

So,  too,  impoverishment  of  the  blood,  which  has 

been  regarded  as  the  cause  of  the  gradual  failure 

in  the  aged,^  is  itself  due  to  imperfect 

Causes  of  fail-  assimilation,    and    leads   to   imperfect 

lire  in  the  gen-         •  i    .•  i  j^     <?   -i 

esis  of  force,  oxidation  and  consequent  failure  m 
the  genesis  of  force.  Imperfect  assim- 
ilation is,  doubtless,  one  of  the  most  important 
links  in  the  chain  of  causes  which  lead  to  the 
general  decay  of  the  bodily  frame.  The  difficulty 
is  to  say  where  this  chain  begins  ;  for  all  the  func- 
tions of  the  body  are  so  linked  together  that  there 
is  not  one  of  them  which  can  be  called  primary, 
upon  which,  when  it  fails,  may  be  laid  the  blame 
of  initiating  the  decay  of  all  the  others.^ 

The  more,  indeed,  we  investigate  the  phenomena 
of  decay,  the  more  clearly  do  we  see  that  this 
does  not  arise  from  any  failure  of  the  sources  of 
potential   energy,   but    solely   from    the   inability 

longer,  term  of  existence." — Koget,  article  "Age,"  in  the 
Cyclopedia  of  Practical  Medicine,  etc. 

1  Vide  articles  on  "Age,"  in  the  Cyclopedia  of  Anatomy 
and  Physiology,  by  Symonds,  p.  82  ;  and  in  the  Cyclopedia  of 
Practical  Medicine,  by  Roget,  p.  39. 

■2  Roget,  loc.  cit. ;  and  Whytt,  On  Vital  Motions,  Edinburgh, 
1751,  p.  270. 


INTR  ODUCTORY  11 

of  the  organism  to  make  use  of  those  presented  to 
it,  because  it  has  itself  become  effete  as  the  direct 
and  necessary  result  of  development. 

In  early  life  the  body  grows  through  the  abun- 
dance of  the  fluid  food,  with  which  every  part  is 
flushed.     The    characteristics    of    the 

.  1  •   1       1  •      Characteris- 

systemic  circulation  upon  which  tins   f^f.^  ^f  tj^Q  g^,.. 

flushing  depends  are,  that  the  ampli-  cuiationin 
1      /-     Ti       N      p     1       1  •        •      eaHi/  life. 

tude  (calibre)  oi  the  large  arteries  is 
great  in  comparison  to  the  size  of  the  heart,  and 
also  to  the  length  of  the  body.  Hence  there  is  a 
low  blood  pressure  and  a  rapid  pulse-rate.  The 
large  amount  of  fluid  in  the  tissues,  the  abundant 
supply  of  nutriment,  and  the  low  blood  pressure, 
coupled  with  the  shorter  time  in  which  the  whole 
circuit  of  the  vascular  system  is  traversed,^  all 
favour  the  diffusion  of  the  blood-plasma  and  the 
rapid  growth  of  the  body.  These  conditions  pre- 
vail during  early  life,  but  are  most  marked  during 
the  first  year.  During  early  life  the  whole  body 
grows  in  every  part,  but  the  growth  of  the  arteries 
in  calibre  does  not  keep  pace  either  with  the 
growth  of  the  body  in  length,  or  with  the  growth 
of  the  heart  in  amplitude  and  strength.  The  nat- 
ural result  is  a  gradual  rise  in  the  blood  pressure, 
and  an  equally  gradual  slowing  of  the  pulse-rate 

1  Twelve  seconds  as  against  twenty-two  in  the  adult.  Vide 
Foster's  Physiology,  1883,  p.  685. 


12  THE   SENILE  HEART 

as  growth  and  age  increase,  until  in  early  man- 
hood growth  is  completed,  and  the  blood  pressure 
reaches  its  highest  norm.  At  this  period  the 
whole  organism  is  full  of  life  and  vigour,  and  is  at 
its  best  in  respect  of  its  capacity  for  bodily  and 
mental  exertion. ^     But  as  development  progresses, 

1  Vide  Die  Altersdisposition,  by  Dr.  F.  W.  Beneke,  Marburg, 
1879,  pp.  7,  12,  14,  and  18.  About  this  time  two  events,  the 
access  of  puberty  and  the  cessation  of  growtli,  have  a  most 
important  influence  in  the  story  of  development.  Beneke  refers 
the  access  of  puberty  to  the  cessation  of  growth.  The  capillary 
system,  during  the  second  stage  of  life  (7-15),  ceases  to  grow 
as  heretofore ;  the  brain  and  large  glands  have  attained  nearly 
their  full  development,  and  the  blood  pressure,  still  rising  in 
the  whole  arterial  and  capillary  system,  finds  its  outlet  in  the 
development  of  the  sexual  organs,  the  glands  of  the  skin,  and 
the  growth  of  the  hair  always  associated  with  maturity  (op.  cit. , 
p.  14).  This  explanation  of  the  physics  of  development  seems 
adequate  enough  so  far  as  it  goes.  The  great  difficulty  is  to 
account  for  the  cessation  of  growth  at  all  in  any  part  of  the 
body.  Geoffrey  Saint- Hilaire  {op.  cit..,  vol.  i.)  has  some  very 
pertinent  and  interesting  remarks  on  this  subject.  He  points 
out  that  dwarfs  are  imperfect  individuals,  usually  impotent ; 
their  growth  and  development  have  both  been  arrested.  But 
inasmuch  as  puberty  alone  puts  an  end  to  the  growth  of  man, 
a  dwarf  may  recommence  his  growth  at  any  time,  even  up  to 
old  age ;  and  Saint-Hilaire  states  that  he  himself  had  observed 
several  instances  of  this  (p.  190,  note).  Giants,  on  the  other 
hand,  are  those  in  whom  growth  has  continued  because  their 
sexual  organs  have  been  slowly  and  incompletely  developed. 
Giants  are  mostly  impotent,  always  feeble,  feminine  in  aspect, 
and  usually  very  shortlived  (p.  192).  In  precocious  children, 
the  rapid  growth  being  early  directed  to  the  sexual  organs,  the 
individual  ceases  to  grow  ;  from  a  gigantic  child  he  may  become, 
if  he  lives,  a  man  of  but  moderate  bulk  (p.  192).     So  it  may 


INTR  ODUC  TOR  Y  13 

the  arterial  coats  slowly  undergo  a  change  of 
structure,   by   which   they   lose    their 

CJhdTlOQS'iTl  tJlB 

elasticity,  and  become  gradually  con-  vascular  sys- 
verted  into  more  or  less  approximately   ^^"^  through 
rigid  tubes. 1     The  effect  of  this  loss 

happen  that  a  child  with  very  active  nutrition  may  become 
either  an  imperfectly  developed,  giant,  or  an  early  developed  (pre- 
cocious) youth  of  moderate  bulk  (piD.  193,  194).  Saint-Hilaire 
merely  states  these  as  facts,  without  in  any  way  attempting  to 
account  for  them.  He  points  out  that  there  are  various  races 
of  men  famous  for  their  bulk  and  stature,  and  others  remark- 
able for  their  diminutive  size ;  and  that  though  food  and  other 
accidents  of  environment  have  an  acknowledged  influence  in 
promoting  and  hindering  growth,  yet  those  races  of  varying 
size  unquestionably  owe  more  to  heredity  (however  acquired) 
than  they  do  to  abundance  of  food,  and  a  comfortable,  easy 
life,  or  the  reverse  (pp.  240,  241).  It  is  the  physics  alone  of 
growth  that  concern  us  :  could  we  know  these  perfectly,  it  would 
suffice  ;  meanwhile  as  these  physics  are  closely  involved  with  the 
progress  and  cessation  of  growth,  it  would  be  of  great  impor- 
tance to  discover  why  we  ever  cease  to  grow.  Herbert  Spencer 
says  that  growth  is  arrested  "because  the  excess  of  absorbed 
over  expended  nutriment  must,  other  things  equal,  become  less 
as  the  size  of  the  animal"  become  greater."  —  Frinciples  of 
Biology^  Vol.  i.,  p.  122.  If  this  were  the  true  reason,  we  should 
all  be  more  nearly  alike  in  size  than  we  are.  Moreover,  though 
this  seems  a  good  enough  reason  for  an  animal  ceasing  to  live 
when  it  attains  a  certain  bulk,  and  thus  seems  applicable  to 
giants,  and  explanatory  of  their  short  lives,  it  does  not  seem 
to  be  a  sufficient  reason  why  we  should  ever  cease  growing 
before  we  reach  that  extreme  bulk,  nor  does  it  give  any  expla- 
nation of  the  very  peculiar  relations  subsisting  between  growth 
and  sexual  development. 

1  ' '  One  common  feature  of  old  age  is  the  conversion  by  such 
a  change ' '  —  that  is,  by  the  replacement  of  a  structured  matrix 


14  THE   SENILE   HEART 

of  resilience  in  the  arterial  coats  is,  that  while 
these  coats  yield  as  formerly  to  the  advanc- 
ing blood-wave,  they  yield  more  slowly,  and 
they  do  not  recover  themselves,  so  that  the  lu- 
men of  the  arteries  undergoes  a  gradual  dilata- 
tion. The  heart  at  the  same  time  tends  to  fail, 
senile  atrophy  begins,  and  in  the  midst  of  our 
fullest  life  Death  himself  lays  his  finger  upon  all 
our  organs.  From  the  dilatation  of  the  arteries 
there  is  a  tendency  to  lowering  of  the  blood  press- 
ure ;  and  to  this  failure  of  the  blood  pressure  has 
been  ascribed  that  obsolescence  of  the  capillaries 
which  is  the  cause  of  the  dry  and  wrinkled  skin, 
the  gray  hair,  and  the  cessation  of  the  sexual  func- 
tions, and  which  is  so  evident  on  the  anatomical 
investigation  of  the  organs  themselves.^  The 
result  of  this  withering  of  the  capillaries  is,  ac- 
cording to  Beneke,  by  diminishing  their  area,  to 
increase  the  peripheral  resistance  to  the  onward 
flow  of  the  blood,  and  thus  to  raise  the  blood 
pressure  within  the  arteries  themselves,  so  that, 
notwithstanding  dilatation  of  these  vessels,  the 
blood  pressure  in  age  is  always  greater  than  it  is 
in  early  youth.  This  view  of  Beneke's  is  not, 
however,  quite  consistent  with  the  physical  facts ; 

by  amorphous  material  —  "of  the  supple,  elastic  arteries  into 
rigid  tubes."  —  Foster,  op.  cit..,  p.  090.  Vide  also  references 
on  p.  20.  1  Beneke,  op.  cit.,  p.  24. 


INTROD  UCTOR  V  .  IS 

circumstances  being  alike,  the  increase  in  the 
arterial  capacity  would  undoubtedly  lower  the 
blood  pressure  within  them ;  but  the  circumstances 
of  age  are  by  no  means  those  of  youth.  In  youth 
the  relatively  large  calibre  of  the  arteries  has  no 
ill  effect  on  the  circulation,  because  though  the 
blood  pressure  is  not  great,  it  is  perfectly  sufficient 
to  keep  up  a  steady  and  continuous  flow  into  the 
capillaries.  In  age,  however,  the  case  is  different ; 
the  loss  of  arterial  elasticity,  while  it  throws  a 
greater  strain  upon  the  heart  itself,  makes  the  out- 
flow into  the  capillaries  approximately  intermit- 
tent, and  thus  lowers  the  blood  pressure  within  the 
capillary  area,  though  it  still  remains  high  within 
the  arteries  themselves.^  The  cessation  of  active 
growth  makes  a  large  network  of  capillaries  un- 
necessary, and  the  fall  of  the  blood  pressure  within 
these  vessels  permits  many  of  them  to  obsolesce. 
The  result,  therefore,  is  identical,  though  the 
steps  by  which  it  is  reached  are  not  exactly  as 
Beneke  has  put  them.  By  the  time  the  heart  has 
succeeded  in  permanently  dilating  the  inelastic 
arteries,  and  has  restored  them  to  their  former 
relative  magnitude,  the  increase  of  the  peripheral 
resistance,  due  to  the  withering  of  the  capillaries, 
is  sufficient  to  prevent  any  material  lowering  of 
the  blood  pressure  from  this  cause.  By  and  by, 
1  Foster,  op.  cit..,  p.  132. 


16  THE  SENILE  HEART 

however,  this  is  gradually  brought  about  by  weak- 
ening of  the  heart  through  failure  of  the  genesis 
of  force,  due  to  failure  of  assimilation  arising  from 
withering  of  the  capillaries  in  the  skeletal  muscles, 
as  well  as  in  all  the  glands  of  the  body. 

Decay  is  thus  the  necessary  and  final  stage  of 
development ;  and  though  it  may  not  be  possible 
to  put  a  finger  upon  any  special  function  or  struct- 
ure, and  to  say.  Here  decay  commences,  yet  erelong 
we  can  positively  say,  Tlii^  is  the  line  along  which 
decay  is  marching,  and  here  is  the  structure  in  which 
we  can  earliest  detect  the  withering  effects  of  age. 

From  our  earliest  days  the  growth  of  our  frame 
is  accompanied  by  a  gradual  condensation  of  tis- 
sue, till  the  gelatinous  pulp  of  the  primitive 
embryo  is  converted  into  the  withered  old  man. 
Every  tissue  partakes  of  this  change  :  the  skin 
becomes  dry,  flaccid,  and  wrinkled ;  the  bones  are 
denser  and  more  brittle ;  the  muscles  participate 
in  the  condensation  incident  to  the  cellular  tissue, 
which  enters  so  largely  into  their  composition; 
the  muscular  fibres  themselves  are  more  rigid, 
diminished  in  bulk,  and  impaired   in 

TithoTiUs  ci 

true  type  of      Contractility,  so  that  they  are  less  read- 

protracted        Qy    r^j-^^j    ^ggg    powerfully   excitcd    by 

stimuli.^     Hence   the    shrunk  shanks, 

tottering  gait,  and  withered  aspect  of  the  aged 

1  Roget,  op.  cit.,  p.  40. 


INTR  OD  UCTOR  Y  17 

man  which  have  crystallized  into  the  figure  of  the 
fabled  Tithonus  as  the  classic  representative  of 
protracted  age.^  It  is  only  in  fable,  however,  that 
Tithonus  suffers  from  the  burden  of  undying  age ; 
in  real  life  his  frailties  promote  his  euthanasia. 
Worn  with  his  weary  tramp  through 
life,   no    longer    able    even   to    totter  ^'^  ^'^"^  ^'^^ 

.  .  Tithonus 

about,  Tithonus  at  last  lays  him  down  aies.   His 

to  rest.      Partly  from  the  loss  of  the  death  is  a  typ- 
ical death 
stimulating  eftect  of  the  little  exercise  from  age. 

he  was  able  to  take,  and  partly  from 
a  similar  cause  to  that  which  has  occasioned  the 
wasting  of  his  skeletal  muscles,  his  powers  of 
assimilation  give  way.  His  blood  becomes  dimin- 
ished in  quantity  and  defective  in  quality ;  the 
brain  centres  for  relative  and  for  organic  life  get 
badly  nourished ;  the  genesis  of  force  becomes 
more  and  more  imperfect ;  slight  wandering  delir- 
ium sets  in,  and  death  from  asthenia  speedily  fol- 
lows. Scenes  anticipatory  of  the  future,  more 
often  memorial  of  the  past,  flit  like  dreams 
through  the  failing  consciousness,  and  the  weary 
mortal  occasionally  dismisses  himself  with  some  re- 
mark bearing  on  his  future  or  his  past.    "Adsum" 

1  His  wife,  Aurora,  obtained  from  Jupiter  the  gift  of  immor- 
tality for  him,  but  forgot  to  ask  for  perpetual  youth  ;  hence, 
Horace  says,  "Longa  Tithonum  minuit  senectus." — Lib.  II., 
carmen  xvi.,  1.  30. 

0 


18  THE  SENILE  HEART 

has  been  the  final  utterance  here,  the  fitting  pre- 
lude to  hereafter.  Charles  Abbot,  the  first  Lord 
Tenterden,  when  dying,  raised  himself  from  his 
couch,  and  saying,  with  all  his  wonted  solemnity, 
"  Gentlemen  of  the  jury,"  fell  back  and  expired ; 
and  the  gathering  glooms  of  death  drew  from  the 
great  schoolmaster  Adam  the  pathetic  and  appro- 
priate farewell,  "  It  grows  dark,  boys,  ^ow.  may 
go."  "  The  great  difference,"  says  Bichat,  "  be- 
tween death  from  old  age  and  death  from  a  sudden 
seizure,  is  that  in  the  former  death  commences  at 
the  periphery  and  terminates  at  the  heart  —  the 
empire  of  death  begins  at  the  circumference  and 
ends  at  the  centre  ;  while  in  the  latter  death  com- 
mences at  the  heart  and  spreads  over  the  body 
generally  —  death  begins  at  the  centre  of  vitality, 
and  gradually  extends  to  its  outmost  bounds."  ^ 
It  is  impossible  to  imagine  any  mode  of  dying  to 
which  Bichat's  description  of  death  from  age  could 
be  more  applicable  than  it  is  to  that  just  described. 
It  is  the  typical  mode  of  dying  from  gradual  de- 
cay. Except  as  to  perpetual  youth,  Tithonus  is 
no  myth,  and  his  mode  of  dying,  though  not  the 
lot  of  every  one,  cannot  fail  to  be  recognized,  and 
is  not  readily  forgo tten.^     It  is  a  mode  of  dying 

1  Becherches  physiologiques  sur  la  vie  et  la  mort^  Paris,  1805, 
p.  151. 

'^  An  admirable  and  most  pathetic  description  of  death  from 


INTR  OD  UCTORY  19 

peculiar  to  advanced  age ;   yet,  even  in  old  age, 
men  die  more  commonly  from  accident  or  disease 
than  from  simple  decay.      Not  because  develop- 
ment has  not  the  same  course  in  every 
one,  and   tends    always   to   the   same     ^^  *^^*^, ,  ^ 

'  "J  measured  by 

end;  but  because  those  tissue  changes,  tissue  change, 
which  mark  the  proofress  of  develop-  *^  ^^^  ^ 

■•■      °  -•-      years. 

ment  from  the  cradle  to  the  grave, 
intensify  after  middle  life  all  the  dangers  of  acute 
diseases,  and  by  accentuating  any  latent  organic 
weakness  or  structural  defect,  inherited  or  ac- 
quired, often  cause  those  to  die  from  age  who 
have  scarcely  begun  to  think  themselves  old. 
Tithonus  the  aged  succumbs  at  last  from  failure 
of  the  genesis  of  force.  He  dies  from  asthenia 
due  to  failure  of  oxidation  following  failure  of 
assimilation,  primarily  induced  by  changes  in  the 
circulatory  system.  We  cannot  trace  the  changes 
in  the  capillaries  and  arteries  beyond  the  vessels 
themselves :  we  know  not  the  cause  of  these 
changes.  But  it  is  an  advantage  to  know,  and 
there  is  a  general  consensus  of  opinion  on  this, 
that  the  arterial  system,  which  leads  the  van  in 
the  development  of  the  body,  is  also  that  upon 

age  is  to  be  found  in  the  Book  of  Ecclesiastes,  Chapter  xii. 
The  authors  of  the  Revised  Version  have  somewhat  added  to 
the  pathos  of  this  description  by  substituting  the  word  "  caper- 
berry  "  for  "  desire." 


20  THE   SENILE  HEART 

which  the  finger  of  decay  is  earliest  laid.^  By 
watching  the  development  of  this  system  and  its 
relations  to  the  heart  and  other  organs,  we  are 
timeously  warned,  and  are  often  able  successfully 
to  oppose  the  beginnings  of  evil.  To  recur  to 
Bichat's  simile,  though  we  cannot  prevent  the  sap- 
ping of  the  outworks,  we  can  reinforce  the  citadel, 
and  thus  we  are  often  able  to  postpone  the  ulti- 
mate surrender.  True,  we  cannot  hope  in  this  way 
to  provide  an  Agerasia^  nor  even  to  restore  the 
patriarchal  ages  ;  but  we  can  assuredly  diminish 
the  number  and  intensity  of  those  side  issues 
which  so  often  bring  life  to  a  premature  termina- 
tion. We  can  greatly  lessen  human  suffering,  and 
we  may  put  it  in  the  power  of  many  more  nearly 
to  attain  the  norm  of  life,  which,  according  to 
Beneke,  is  from  ninety  to  one  hundred  years.^ 

1  Vide  articles  on  "Age"  in  the  Cyclopedia  of  Practical 
Medicine,  p.  38,  and  in  the  Cyclopedia  of  Anatomy  and  Phys- 
iology, p.  77.  Vide  also  Gimbert,  "  Memoire  sur  la  structure 
et  sur  la  texture  des  arteres,"  Journal  de  V Anatomic,  Vol.  ii., 
p.  648.  Valerie  Schiele-Wiegandt  says:  "In  bezug  auf  das 
Alter  ergiebt  sich  folgendes  Gesetz  sowohl  bei  Manuern  als 
auch  bei  Frauen  nelimen  im  Grossen  und  Ganzen,  entsprechend 
den  hoheren  Altersperioden,  in  alien  arterien  umfang  und  dicke, 
respective  media  und  intima,  allmahlich  steigend  zu"  {Vi7'- 
choufs  Archiv.y  Bd.  Ixxxii.,  S.  36)  ;  and  Roy  has  found  that 
sometimes  before,  and  certainly  always  after,  middle  life,  the 
arteries  begin  to  lose  their  elasticity  {Journal  of  Physiology, 
Vol.  iii.,  p.  125,  etc.). 

2  Op.  cit.,  S.  26. 


CHAPTER  II 

HOW   THE   HEART   IS   AFFECTED   BY   AGE 

Two  organs  largely  escape  the  effects  of  normal 
failure  —  the  brain  and  the  heart.  Goethe,  Von 
Humboldt,  Leopold  Ranke,  Mrs.  Som- 

Heart  and 

erville,  and  Thomas  Carlyle,  are  mem-  i,rain  largely 
orable  examples  of  those  who  have  done  ^^^^'^p^  ^^mZe 

failure. 

excellent  brain  work  at  very  advanced 
periods  of  life ;  and,  indeed,  the  wisdom  of  age 
would  never  have  become  proverbial  had  the  brain 
not  been  observed  to  functionate  with  its  wonted 
integrity  even  in  hoar  age.  In  typical  death  from 
age  the  mind  can  scarcely  be  said  ever  to  fail ;  it 
wavers,  indeed,  amid  the  gathering  glooms  of 
death,  but  till  then  its  acuteness  and  energy  are 
often  scarcely  diminished.     The  brain 

,       ,  1        1      J.    1  The  mainte- 

remams  visforous  to  the  last,  because  ^,,        .-.     . 

&  '  nance  of  oram 

its  nutrition  is  specially  provided  for.  power  spe- 
At  or  after   middle   life,  though   the  ^J^g^i^^.^' 
arteries    of    the    body   generally   lose 
their   elasticity   and   become    slowly   dilated,  the 
internal  carotids  continue  to  retain  their  pristine 

21 


22  THE   SENILE  HEART 

elasticity  and  calibre,^  so  that  the  blood  pressure 
within  the  cerebral  capillary  (nutritive)  area  re- 
mains normally  higher  than  within  the  capillary 
area  of  any  other  organ  in  the  body ;  the  cerebral 
blood  paths  are  thus  kept  open,  and  the  brain 
tissue  itself  is  kept  better  nourished  than  the 
other  tissues  of  the  body. 

The  corollary  from  this  is  important :  brain 
failure,  not  being  a  necessary  characteristic  of  age, 
must  always  be  looked  upon  as  an  indication  of 
local  malnutrition,  and  for  this  cardiac  failure  or 
arterial  atheroma  are  most  often  to  blame.  In  the 
one  case,  improvement  may  be  expected  from  treat- 
ment; in  the  other,  the  failure  of  treatment  but 
confirms  the  provisional  diagnosis. 

As  for  the  heart,  this  organ  has  long  been 
The  heart  is  known  to  be  hypertrophied  in  all  old 
always  found    people.     M.  Bizot,  in  his  well-known 

Mjpertrophied  •  i     i  -r»      i         i  i 

at  advanced  paper  entitled  "  Recherches  sur  le 
^9^^'  Coeur   et    le    Systeme    Arteriel    chez 

I'homme,"  ^   tells    us   that    "  old    age    is   in   both 

1  Beneke,  op.  cit..,  p.  24,  "Die  grossen  Arteriellen  Gefas- 
stamme  erfahren  dagegen  eine  immer  mehr  zunehmende  Er- 
weiterung,  und  erreichen,  mit  ausnahme  der  Carotides  commu- 
nes., relativ  zur  korperlange  eine  nocli  betrachtlicher  Weite,  als 
im  ersten  Lebensjahre."  Also,  op.  cit..,  p.  75;  and  Constitu- 
tion und  ConstitutioneUes  Kranksein  des  Menschen,  von  Dr. 
F.  W.  Beneke,  Marburg,  1881,  p.  42. 

2  Vide  Memoires  de  la  Societe  Medicate  d^  Observation,  Tome 
premier,  Paris,  1837,  p.  262. 


HOW  THE  HEART  IS  AEFECTED  BY  AGE       23 

sexes  that  period  in  which  the  heart  attains  its 
greatest  dimensions,"  so  that  if  it  be  correct  "  to 
compare  the  size  of  the  heart  at  thirty  years  of 
age  to  that  of  the  fist  of  the  subject,  at  sixty  the 
heart  will  be  found  to  be  much  larger  if  it  is  not 
abnormal."  ^ 

Charcot,  in  his  "Lectures  on  Senile  Diseases,"  ^ 
says  that,  unlike  every  other  organ  in  the  body 
but  the  kidney,  the  heart  preserves  even  in  old 
age  the  dimensions  of  middle  life ;  and  he  adds 
that  in  some  old  people  "the  heart  may  even 
undergo  a  real  hypertrophy." 

Cohnheim  is  of  a  similar  opinion  ;  he  says,  "  The 
heart  of  very  old  persons  does  not,  as  a  rule,  par- 
ticipate in  the  general  atrophy  of  the  body,  and 
especially  of  the  muscles,  but  rather  increases  in 
mass  and  volume."  ^ 

Beneke's  experience,  on  the  other  hand,  sufficed 
to  convince  him  that  only  those  reach  advanced 
life  who  have  been  originally  possessed  of  large 
and  strong  hearts.*     According  to  Beneke  age  is 

1  "  Si  done  a  trente  ans  le  coeur  doit  avoir  le  volume  du 
poing  du  sujet,  a  soixante  il  doit  etre  plus  volumineux,  sous 
peine  d'etre  dans  une  condition  anormale.  La  vieillesse  est, 
dans  les  deux  sexes,  I'epoque  de  la  vie  a  laquelle  le  coeur  offre 
le  volume  le  plus  considerable  "  (op.  ciY.,  p.  275). 

2  New  Sydenham  Society's  Translation,  p.  28. 

3  Lectures  on  General  Pathology^  New  Sydenham  Society's 
Translation,  Vol.  i.,  p.  106. 

*  Die  AUersdisposition,   p.  24.     "  Wenn   die  von  mir  auf 


24  THE   SENILE   HEART- 

not  a  possible  inheritance  of  all,  but  only  of  a 
select  few  destined  to  it  from  birth.  I  myself, 
however,  have  seen  too  many  weak  hearts,  and 
even  hearts  mechanically  defective,  attain  advanced 
age  to  regard  this  idea  as  even  approximately  true. 

Charcot  distinctly  recognizes  the  senile  hyper- 
trophy of  the  heart  as  the  legitimate  result  of  the 
senile  alteration  of  the  arteries.  But  he  limits 
the  change  to  "  some  old  people,"  and  regards  it 
as  pathological.^ 

Bizot,  on  the  other  hand,  states  explicitly  that 
this  senile  hypertrophy  of  the  heart  occurs  in  all 
without  exception  ;  that  it  is  mainly  limited  to  the 
left  ventricle,  though  the  right  ventricle  also 
shares  in  it  to  a  limited  extent;  and  that  it  is 
invariably  associated  with  dilatation  of  the  arte- 
rial system  and  thickening  of  the  arterial  walls. 
These  changes  affect  every  one,  man  and  woman 
alike,  and  continually  increase  as  age  advances.'-^ 
But  changes  which  happen  to  every  one,  and  con- 
tinually progress  as  age  advances,  form  part  of 
our  development  and  are  physiological,  and  not 

Tab.  I,  gezeichnete  curve  (cles  Herzensvolum)  in  den  70ger 
Jahren  noch  wieder  eine  Hebung  zeigt,  so  lasst  dieselbe  kaum 
eine  andere  Erklarung  zu  als  dass  diese  hohe  Altersstufe  iiber- 
liaupt  nur  von  im  allgemeinen  kraftigen  Naturen  erreicht  wird, 
und  dass  diese  aucli  von  Haus  aus  sclion  ein  grosseres  Herz- 
volum  besitzen." 

1  Loc.  cit.  "^  Vide  op.  cit.,  pp.  275,  286,  288,  301,  etc. 


HOW  THE  HEART  IS  A  FEE  C  TED  BY  AGE       25 

pathological.  They  may  often  enough  be  asso- 
ciated with  pathological  alterations  of  the  arterial 
coats,  but  this  is  not  always  the  case  even  at  the 
most  advanced  ages,  and  the  merely  normal  loss 
of  arterial  elasticity  is  quite  sufficient  to  account 
for  the  change  in  the  structure  of  the  heart. 

The  normal  elasticity  of  the  arterial  coats  con- 
verts the  intermittent  blood  flow  from  the  heart 
into  a  continuous  flow  into  the  capillaries,  and 
when  this  elasticity  fails,  the  outflow  into  the 
capillaries  becomes  approximately  intermittent,  the 
blood  pressure  within  their  area  falls,  many  of 
them  obsolesce,  and  the  most  obvious,  if  not  quite 
the  earliest,  of  our  senile  changes  are  initiated. 
On  the  other  hand,  this  intermittent  outflow  from 
the  arteries  accumulates  the  blood  within  them,  and 
raises  the  intra-arterial  blood  pressure.^  The  result 
of  this   is   that   the    left  ventricle   is   m  ^ 

The  sources  of 

called    upon    for    extra    exertion,    in  vigour  in  the 

1        ,      1     •  ,1  j_      •   1  ^  senile  heart. 

order  to  bring  the  arterial  and  venous 
blood  pressures  and  the  velocity  of  the  circula- 
tion to  their  normal  values.  Fortunately  the 
heart  always  works  so  Avell  within  its  powers,  that 
in  health  it  readily  responds  to  any  call  of  this 
character. 2     The  response  of  the  left  ventricle  to 

1  Vide  antea.,  p.  15. 

2  Vide  Balfour's  Clinical  Lectures  on  Diseases  of  the  Heart 
and  Aorta,  Churchill,  London,  1882,  second  edition,  p.  84,  and 
p.  137,  note. 


26  THE   SENILE   HEART 

this  call  is  necessarily  followed  by  the  flushing  of 

the  myocardium  at  each  pulsation  with  blood  at  a 

pressure  considerably  above  the  normal,  hence  — 

other   things   being   equal  —  metabolism   is    more 

complete  and  nutrition  more  perfect.     Add  to  this 

that  according  to  Leichtenstern  ^  the  haemoglobin 

is  always  found  to  be  increased  after  sixty,  and 

we  see  that  the  conditions  at  and  after  middle 

life    are  —  in    health  —  most    favourable    for   the 

gradual  development  of  hypertrophy  of  the  heart, 

and   especially   of    the    left    ventricle.     Nay,  so 

favourable  are  those  conditions  that  weak  hearts, 

and  even  hearts  mechanically  defective,  are   able 

to  profit  by  them,  so  that  many  hearts  at  seventy 

are  stronger  and  better  fitted  for  the  discharge  of 

their   functions    than    they   were    at   sixty.      The 

changes  in  the  arteries  due  to  age  pro- 
Senile  vascu-  i      i       i       •  -i  i 

lar  changes       cccd  slowly,  imperceptibly,  and  so  tar 

proceed  insen-    ^^  ^^^q  individual  himself  is  concerned, 
sibly. 

unconsciously.     If  the  heart  responds 

normally  to  the  call  for  extra  exertion  demanded 

of  it,  the  individual  gradually  descends  into  the 

vale  of  years   quite    unconscious   whether  he  has 

a  heart  or  not.     If  this  knowledge  is  forced  upon 

him,  trouble  is  not  far  off. 

Various  circumstances  may  bring  to  mind  that 

1  Untersuchungen  uher  den  Hcemoglobingehalt  des  Blutes  in 
gesunden  and  Icranken  Zustdnden,  Leipzig,  1878,  S.  29. 


HOW  THE  HEART  IS  AFFECTED  BY  AGE      27 

we  have  a  heart;  its  function  may  be  disturbed 
by  an  excessive  strain  thrown  on  the  myocardium 
by  an  early  and  excessive  development  of  arterio- 
sclerosis, the  arteries  in  early  life  being  sometimes 
as  hard  and  tortuous  as  they  are  ever  found  to  be 
even  at  the  most  advanced  as^e.     Ven-   „  , 

o  Causes  of 

tricular  embarrassment  is  produced  by  trouble  to  the 
whatever  increases  peripheral  resist-  ^^"'^  ^  ^^^ ' 
ance.  We  have,  therefore,  to  reckon  not  only 
with  the  alterations  in  the  elasticity  and  structure 
of  the  arteries,  but  also  with  the  permanent  con- 
traction of  the  vascular  area  due  to  capillary 
obsolescence,  as  well  as  with  those  temporary  con- 
tractions arising  from  reflex  causes  of  various 
origins,  which  not  only  embarrass  the  circulation, 
but  also  give  rise  to  sundry  symptoms  of  very 
serious  import.  Moreover,  peripheral  resistance 
is  greatly  increased  by  any  augmentation  of  the 
quantity  of  the  blood,  whether  that  be  caused  by 
plethora  or  hydrsemia,  and,  as  we  can  readily 
understand,  it  may  be  notably  affected  by  the  con- 
dition of  the  vascular  environment.^ 

In  estimating  the  various  causes  which  hinder 
the  passage  of  the  blood  from  the  arteries  to  the 

^  Vide  Text-book  of  Pathology,  by  D.  J.  Hamilton,  M.B., 
etc.,  London,  1889,  Vol.  i.,  p.  630  and  p.  694.  Donders  seems 
to  have  been  the  first  to  direct  attention  to  the  importance  of 
the  vascular  environment  in  relation  to  blood  pressure.  Vide 
Physiologie  des  Menschen,  Leipzig,  1856,  Vol.  i.,  S.  169. 


28  THE   SENILE   HEART 

veins,  and  thus  increase  the  intra-arterial  blood 
pressure,  we  are  too  apt  to  overlook  the  condition 
of  the  tissues  generally.  We  figure  to  ourselves 
the  blood  going  its  round  through  arteries,  capil- 
laries, and  veins,  as  it  were  through  naked  tubes, 
forgetting  that  nutrition  is  extra-vascular,  that  the 
tissues  are  always  flooded  with  blood-plasma,  and 
that  this  fluid  diffuses  the  elastic  pressure  of  the 
tissues,  and  binds  it  to  that  of  the  arterial  wall.  The 
tissues  themselves  lose  their  elasticity  through  age, 
—  like  the  arteries,  —  and  this  cannot  be  renewed. 
But  the  influence  of  the  environment  depends  not 
so  much  upon  this  as  upon  the  amount  of  fluid 
filling  the  interspaces  of  these  tissues,  and  this 
varies  both  as  to  quantity  and  quality  according 
to  the  state  of  the  circulation,  the  quality  of  the 
blood,  and  the  integrity  of  the  secreting  organs 
upon  which  this  quality  depends. 

On  the  side  of  the  heart  embarrassment  is 
brought  about  by  all  those  circumstances  and  con- 
ditions of  life  which  of  themselves  weaken  that 
organ,  and  consequently  intensify  the  action  of 
those  hindrances  that  have  just  been  referred  to. 

Acute  diseases  weaken  the  heart  by  interfering 
with  its  nutrition  and  exhausting  its  nervous 
energy.  Sudden  critical  or  precritical  cardiac  col- 
lapse is  a  thing  we  are  all  well  acquainted  with. 
Sudden  death  from  cardiac  failure  that  not  infre- 


HO IV  THE  HEART  IS  AFFECTED  BY  AGE       29 

quently  follows  any  abrupt  exertion  —  sucli  as 
sitting  up  or  getting  out  of  bed  —  during  convales- 
cence from  acute  disease,  is  also  not  unknown. 
But  tbere  is  a  third  mode  of  dying  from  the  heart 
after  acute  disease,  which  is  neither  so  common 
nor  so  generally  recognized ;  in  this  some  trifling 
exertion,  undertaken  before  the  heart  has  had 
time  to  reaccumulate  sufficient  energy,  starts  an 
ingravescent  asthenia  from  which  there  is  no 
recovery. 

Death  from  the  heart,  in  any  of  those  modes, 
is  naturally  most  apt  to  occur  after  middle  life, 
first  because  the  cardiac  energy  is  then  more 
readily  exhausted,  and  second  because  its  action 
is  already  embarrassed,  by  one  or  more  of  the 
causes  of  peripheral  resistance  just  alluded  to. 

Apart  from  acute  disease,  which,  as  we  see,  is 
more  apt  to  initiate  death,  rather  than  heart  trouble, 
chronic  disease  has  an  influence  in  this  direction, 
but  chiefly  those  forms  of  it  which  weaken  the 
myocardium  or  impoverish  the  blood  without 
materially  diminishing  the  amount  of  the  circu- 
lating fluid.  Long-continued  dyspepsia  is  well 
known  as  a  common  cause  of  heart  trouble ; 
sometimes  it  is  only  a  symptom,  but  often  it  is  a 
cause  as  well. 

Loss  of  blood  from  any  cause,  either  sudden 
and  considerable  or  more  continuous  and  in  less 


30  THE   SENILE  HEART 

amount,  weakens  the  myocardium  and  leads  to 
heart  trouble,  which  worsens  as  hydraemia  is  estab- 
lished. Any  other  discharge  which  has  a  similar 
effect  is  followed  by  a  similar  result.  Sexual 
excess  has  an  equally  ill  effect,  probably  quite 
as  much  from  loss  of  nervous  energy  as  fi'om  any 
drain  on  the  system. 

Over-indulgence  in  food  induces  plethora  —  a 
most  dangerous  condition  for  any  one  with  a  weak 
heart.  Plethora  produces  corpulency  and  loads 
the  tissues  with  fat ;  this  weakens  their  structure, 
and  by  making  the  cardiac  muscle  less  fit  for  its 
function,  it  intensifies  the  action  of  the  peripheral 
obstruction  it  helps  to  cause  in  inducing  heart 
trouble.  The  abuse  of  stimulants  and  narcotics 
is  a  most  fruitful  source  of  senile  heart  trouble, 
and  when  conjoined  with  gluttony  the  combina- 
tion is  the  most  potent  source  of  heart  trouble 
we  could  have. 

Sudden,  violent,  or  unduly  prolonged  exertion 

is  a  fruitful  source  of  heart  trouble  at  all  ages,  but 

it  acts  with  tenfold  efficacy  after  middle  life,  and 

is  a  not  infrequent  cause  of  an  abrupt  termination 

to  life  itself.^ 

1  The  influence  of  overwork  and  strain  in  producing  cardiac 
dilatation  has  long  been  known,  and  has  been  well  described 
by  Dr.  Thomas  Clifford  Allbutt  in  Vol.  v.  of  St.  George's 
Hospital  lieports,  1870  ;  Dr.  J.  M.  Da  Costa,  American  Journal 
of  Medical   Sciences,  January,  1871,  p.   17  ;  A.  B,  11.  Myers, 


HOW  THE  HEART  IS  AFFECTED  BY  AGE      31 

Lastly,  emotion  of  every  kind  has  long  been 
recognized  as  having  an  important  influence  on 
the  heart's  action  and  functions,  and  as  a  factor 
we  dare  not  neglect  in  investigating  the  etiology 
of  cardiac  disease,  and  especially  of  sudden  car- 
diac failure. 

Inhibition  of  the  heart's  action  by  violent  emo- 
tion is  a  well-known  though  unusual  cause  of 
sudden  death;  and  contrary  to  what  one  would 
expect,  joyous  emotions  are  much  more  fatal  than 
grief  or  sorrow.^ 

But  such  a  tragedy  as  this  is  infinitely  rare  in 
comparison  with  the  pathetic  manner  in  which  life 
is  every  day  shortened  by  the  petty  troubles,  anx- 
ieties, and  worries  which  are  of  daily  occurrence. 
The  less  intense  but  more  persistent  emotion 
keeps  up  a  continual  inhibition  of  the  heart's 
action  in  a  lesser  degree.  This  impairs  the  ven- 
tricular systole,  and  coupled  with  those  vascular 
conditions  which  after  middle  life  favour  cardiac 
dilatation,  often  precipitates  heart  trouble  in  those 

surgeon,  in  Etiology  and  Prevalence  of  Disease  of  the  Heart 
among  Soldiers^  London,  1870.  Also  in  Zur  Lehre  von  der 
TJeheranstrengung  des  Herzens^  von  Johannes  Seitz,  M.D., 
Berlin,  1875 ;  and  in  Die  Herzkrankheiten  in  Folge  von  TJeher- 
anstrengung^ von  E.  Ley  den,  Berlin,  1886. 

1  Eor  many  instances  of  sudden  death  from  emotion,  vide 
A  Treatise  on  Experience  in  Physic^  London,  1772,  Vol.  ii., 
p.  268.  This  is  an  anonymous  translation  of  a  work  by  Johannes 
Georgius  Zimmermann. 


32  THE   SENILE  HEART 

who  might  otherwise  have  escaped.  There  are 
few  of  us  who  have  been  in  practice  for  even  but 
a  short  time  who  have  not  had  occasion  to  note 
the  development  of  serious  cardiac  symptoms  from 
the  trouble  arising  out  of  untoward  domestic 
affairs,  the  worry  of  an  unsuccessful  business,  or 
even  the  wear  and  tear  of  a  too  successful  business 
which  has  outgrown  the  physical  powers  of  its 
manager.^ 

The  morbid  anatomist  finds  after  death,  and 
ascribes  to  senile  degeneration,  many  conditions, 
such  as  pigmentary  involution,  fatty  degeneration, 
aneurism,  and  rupture  of   the  heart.^     But  none 

1  E.  Ley  den,  op.  cit.^  p.  47,  says  :  "  Die  alten  Aerzte  wussten 
es  sehr  wohl,  das  Gemiithsbewegungen  und  Leidenschaften, 
Zorn,  besonders  aber  Gram  und  Schmerz  Herzkrankheiten  zu 
erzeugen  im  Stande  sind.  Die  neuere  Medizin  hat  diese  Er- 
falirung  ziemlich  vernachlassigt,  doch  wird  jeder  erfahrener 
Praktiker  Beispiele  davon  anfiihren  konnen.  Icli  selbst  habe 
sine  Anzahl  solcher  Falle  beobachtet.  Sie  haben  in  ihren 
Symptomen  und  ihren  Verlaufe  eine  auffalige  Ueberein- 
stimmung  mit  den  Fallen  von  Korperlicher  Ueberanstrengung 
des  Herzens  und  Man  konnte  versucht  sein  sie  als  psychisclie 
Ueberanstrengung  jenen  an  die  Seite  zu  stellen.  Die  Analogie 
besteht  sowohl  darin,  dass  das  auffaligste  Symptom,  nahmlich 
die  Arythmie  und  die  Herzdilatation  sich  ebenfalls  in  Folge 
von  psychischen  Einfliissen  entwickeln,  als  audi  darin,  dass 
zwei  stadien  der  Krankheit  untersclieiden  werden  kunnen,  das 
erste  der  Herzerithismus,  das  zweite  die  organische  Herzdilata- 
tion." 

2  Vide  Hamilton,  op.  cit..,  pp.  582,  587,  etc.  Sclerosis  and 
waxy  degeneration  are  sometimes  reckoned  as  senile  changes, 
but  the  one  is  the  result  of  inflammation,  and  the  other  of  a 


HOl^V  THE  HEART  IS  AFFECTED  BY  AGE       33 

of  these  morbid  states  have  any  pathognomonic 
symptoms ;  it  is  only  when  they  affect  the  heart's 
action  that  they  come  under  the  cog-   „      ^.  , , 

'J  o     Essential  le- 

nizance  of  the  physician.  It  is  much  sion  of  the 
the  same  with  the  senile  heart ;  its  ^^^^  ^  ^'^^ 
essential  lesion  is  a  weakened  myocardium,  rarely 
without  dilatation  of  the  cavities.  This  dilatation 
is  caused  by  overstrain,  occasionally  from  actual 
over-exertion,  but  far  more  frequently  slowly  in- 
duced by  causes  which  are  partly  physical  and 
partly  nervous  in  their  origin. 

The  symptoms  of  this  weakened  myocardium 
vary  somewhat  in  each  case,  but  they  have  a 
generic  similarity  in  all.  Precordial  anxiety  is 
usually  what   is   first    complained   of,    „      ,        . 

'J  ^  '    Symptoms  of 

and  however  indefinite  this  may  sound  the  senile 
it  is  a  source  of  extreme  distress  to 
the  patient.  Breathlessness,  pain,  or  cardiac  irreg- 
ularity, in  one  or  other  of  its  many  forms,  are  also 
early  symptoms,  and  sometimes  the  case  is  accent- 
uated by  the  conjunction  of  two  or  more  of  these 
symptoms. 

As  these  symptoms  may  all  be  present  in  the 

general  blood  disorder ;  and  both  may  occur  at  any  age.  Ham- 
ilton, op.  cit.,  p.  588,  etc.  Vide  also  Etude  sur  le  Coeur  Senile, 
par  le  Dr.  Ernesto  Odriozola.  Paris,  1888.  Huber,  however, 
inclines  to  reckon  sclerosis  of  the  myocardium  as  a  purely 
senile  disease,  seeking  its  origin  in  arterio-sclerosis  alone. 
Vide  Archivf.  Patholog.  Anatomie,  Bd.  Ixxxix.,  1882,  S.  236. 


34  THE   SENILE  HEART 

absence  of  any  definite  signs  of  any  cardiac  lesion, 
they  are  often  grouped  under  the  somewhat  indefi- 
nite term  of  a  Nervous  Heart.  A  term  appli- 
cable enough  if  only  employed  to  signify  that  these 
symptoms  are  brought  about  through  the  agency 
of  the  nervous  system,  but  quite  incorrect  if  em- 
ployed to  suggest  that  these  symptoms  have  no 
basis  of  physical  change  in  the  heart  itself. 

In  its  later  stages  the  senile  heart,  in  one  of  its 
forms  at  least,  is  the  Luxus  Herz  of  German 
authors,  the  Gouty  Heart  of  our  writers.  The 
term  "gouty  heart"  is  indeed  equally  applicable  to 
its  early  as  well  as  to  its  later  stages,  inasmuch  as 
those  vascular  changes  which  superadd  the  gouty 
element  proceed  "pari  passu  with  those  which  origi- 
nate the  senile  heart  itself,  and  are  closely  linked 
with  them.  It  is  convenient,  moreover,  to  have 
such  a  term  to  apply,  as  few  people  object  to  be 
called  gouty,  though  many  resent  being  called 
either  nervous  or  old. 


CHAPTER  III 

THE  SYMPTOMS   AND   SIGNS   OF   THE   SENILE 
HEART 

It  may  be  accepted  as  an  axiom  that  all  cardiac 
symptoms  complained  of  after  middle  life,  that  can- 
not be  distinctly  referred  to  some  evi- 
dent disease,  or  to  some  affection  of  the  "^''.^''''^  ^''/'^^' 

'  a.ttve  vjeak- 

cardiac  mechanism  due  to  disease,  may  ness  of  the 
be  regarded  as  orig^inating^  in  actual  or  "*2/ocarc^^m/^ 

&  &  &  tJiQ  origin  of 

relative  weakness  of  the  myocardium,   the  symptoms 
These  symptoms  may  be  of  the  most  ^^^^^^^^^  ^^'"  ^ 
varied  character. 

The  heart  working  easily  within  its  powers  has 
its  work  —  actual  or  relative  —  gradually  increased, 
till  it  reaches  a  point  when  it  makes  itself  felt.  No 
longer  unconscious  of  the  existence  of  a  heart,  the 
individual  becomes  uneasily  cognizant  of  the  pres- 
ence of  that  orp-an.     The  earliest  indi-    j.  .  .,.       . 

o  Definition  of 

cation  of  this  is  a  feeling  of  emptiness  precordial 
and  uneasiness  in  the  left  chest,  very  ^^^^^  ^^' 
aptly  expressed  by  the  term  Precordial  anxiety. 
If  we  examine  the  heart  at  this  stage,  we  find 

35 


36  THE   SENILE  HEART 

on  palpation  that  any  sensation  of  pulsation  in 
„.      ,   ,  the   cardiac   area  is  but  feeble,  while 

Signs  to  he  ' 

found  at  this  the  apex  beat  itself  is  at  the  best  weak 
stage.  ^^^^  ^^^  j^^  quite  imperceptible  ;   the 

percussion  dulness  is  normal ;  on  auscultation  the 
sounds  are  normal,  or,  if  there  is  any  change  at 
all,  the  aortic  second  is  accentuated.  These  are 
indications  of  weakness  of  the  myocardium,  and 
the  accentuated  aortic  second,  if  present,  is  an 
indication  that  to  the  normal  loss  of  arterial  elas- 
ticity there  has  been  superadded  a  dilatation  of  the 
ascending  part  of  the  aorta.^  Being  weak,  the 
heart  is  erethistic,  it  is  irritable,  and  its  action  is 
readily  excited  or  deranged  by  exertion,  or  by 
emotion,  or  by  any  other  cause  of  reflex  disturb- 
ance of  the,  innervation.  Hence  to  precordial 
anxiety  we  have  superadded  at  least  occasional 
irregularity  of  the  heart's  action  in  relation  to 
rate,  force,  and  rhythm. 

The  heart  beats  because  its   muscular  fibre  is 
incompletely    differentiated,  and   still 

J^0VS71XGTltS  of 

the  heart  pri-  retains  the  power  of  spontaneous 
mordiai  in       movement  possessed  by  all  primordial 

character.  2      t-i.       i         ^' 

protoplasm.''  Ine  hearts  energy  re- 
sides in  its  muscular  fibre,  and  its  quality  depends 
upon  the  perfection  of  the  cardiac  metabolism. 

1  Balfour,  op.  cit.,  p.  31. 

2  Foster's  Text-book  of  Physiology,  5th  edition,  1888,  p.  288 
et  antea. 


ITS  SYMPTOMS  AND   SIGNS  37 

The  nervous  system  neither  initiates  nor  main- 
tains the  rhythmic  movements  of  the 
heart,   but   it   controls    and    regulates  ^^^^^^^^Z 

'  ®  the  nervous 

them,  and  through  it  these  movements  system  on  the 
may  be   variously  modified  and  even    ^«^f««^«^^ 

•^  "^  ments. 

arrested. 

The  agency  by  which  the  cardiac  movements 
are  controlled  consists  of  a  network  of  nervous 
filaments  covering  the  surface  of  the  heart,  partic- 
ularly at  its  base.  On  the  one  side,  this  network 
is  connected  with  various  nervous  ganglia,  scat- 
tered throughout  the  substance  of  the  heart,  par- 
ticularly at  the  junction  of  the  sinus  venosus  with 
the  auricle,  and  in  the  auriculo-ventricular  sulcus. 
On  the  other  side  this  network  unites  into  three 
distinct  nervous  cords,  each  of  which  plays  a 
special  part  in  regulating  the  movements  of  the 
heart.  One  of  these  cords  (^,  Fig.  1)  passes 
through  the  first  dorsal  and  the  last  cervical  gang- 
lion into  the  sympathetic  nerve,  and  through  it 
there  pass  to  the  heart  those  impulses  which  in- 
crease the  rate  of  its  pulsations  and  augment  their 
force.^  Acceleration  and  augmentation  of  the  pul- 
sations are  not,  however,  necessarily  coincident.^ 

1  Untersuchungen  ueber  die  Innervation  des  Herzens,  von 
Albert  v.  Bezold,  Leipzig,  1863,  erste  Abtheilung,  S.  162. 

2  ' '  Sometimes  the  one  result,  and  sometimes  the  other  being 
the  more  prominent."  — Foster,  op.  cit.,  p.  294.  Vide  also  Roy 
and  Adami,  Transactions  of  the  Boyal  Society,  Vol.  183,  p.  240. 


38 


THE   SENILE  HEART 


the  heart  and 
their  actions. 


At  times  we  have  a  rapid  heart-beat  with  a 
quick,  large,  and  full  pulse,  but  at  other  times 
the  heart-beat  is  rapid  while  the  pulse  remains 
small  (^vide  Tremor  cordis  and  Tachycardia,  j90sfea). 
Further,  it  is  through  this  nerve  that  the  cardiac 
metabolism  is  effected,  and  its  energy  set  free  — 
it  is  the  Kataholie  nerve  of  the  heart.^ 

The  other  two  nervous  cords  which  pass  from 
the  cardiac  plexus  (6r  and  F^  Fig.  1),  both  enter 
^^  ^    and   ascend  to  the  brain   alonsf  with 

The  nerves  of  ° 

the  vagus  nerve  (^,  Fig.  1),  but  each 
has  its  separate  origin  and  function. 
The  superior  cardiac  nerve  (.F,  Fig.  1)  is  an  affer- 
ent nerve,  and  con- 
veys from  the  heart 
a  controlling  influ- 
ence to  the  vaso- 
motor centre  in  the 
medulla  oblongata 
that  regulates  the 
movements  of  the 
arterioles,  so  that 
when  a  heart  is  la- 
bouring against  a 
blood  pressure  too 
^^'  ^'  high  for  its  powers, 

an  impulse  from  the  heart  to  this  centre  inhibits 
1  Gaskell,  Journal  of  Physiology,  Vol.  vii.,  pp.  41  and  46. 


ITS  SYMPTOMS  AND   SIGNS  39 

the  constrictor  influences  and  tempers  down  the 
blood  pressure  to  suit  the  cardiac  strength .^  It  is 
often  called  the  Depressor  Nerve  of  the  heart. 

The  inferior  cardiac  nerve  (^,  Fig.  1),  though 
it  leaves  the  chest  in  the  vagus  bundle  and  is 
always  referred  to  as  a  branch  of  the  vagus  nerve 
and  its  action  as  vagus  action,  is  really  more 
closely  connected  with  the  spinal  accessory  than 
with  the  vagus  proper,  and  has  a  distinct  root  of 
its  own.  Von  Bezold  believed  that  this  nerve  was 
in  constant  action  and  thus  supplies  the  natural 
tonicity  to  the  heart.^  In  the  present  day  this 
tonicity  seems  rather  to  be  regarded  as  the  prop- 
erty of  the  cardiac  muscular  fibre  and  to  depend 
upon  the  perfection  of  its  metabolism.  The  action 
of  the  vagus  is  Anaholic;  it  inhibits  the  action  of 
the  augmentor  or  katabolic  nerve,  it  slows  and 
reduces  the  force  of  the  auricular  action,  and  may 
even  wholly  arrest  it  for  hours.  On  the  ventricles 
the  vagus  has  not  so  powerful  an  effect;  strong 
stimulation  of  the  vagus  may  indeed  arrest  the 
action  of  the  ventricles,  but  never  for  a  period 
long  enough  to  endanger  life.  When  the  vagus 
excitation  reaches  a  certain  degree  (varying  in 
different  animals),  the  ventricles  begin  to  beat 
independently  of  the  sinus  and  the  auricles,  and 
this  idio-ventricular  action,  at  first  slow  and  irreg- 
1  Foster,  op.  cit.,  p.  351.  2  q^^  g^^.,  S.  84. 


40  THE  SENILE  HEART 

ular,  gradually  becomes  fairly  rapid  and  almost 
completely  regular  in  its  rhythm.  The  interfer- 
ence of  the  sinus  and  ventricular  rhythms  with 
^,  ,     each  other  is  the  usual  cause  of  irreo:- 

The  cause  of  o 

cardiac  irreg-    ularity  of  the   heart's   action,  though 

w  an  y.  irregularity  may  also  be  brought  about 

by  the  auricles  not  responding  to  all  the  impulses 
which  reach  them  from  the  sinus.^  Irregularity 
of  action  diminishes  efficiency  of  the  heart  with- 
out reducing  its  expenditure  of  energy.  This 
^  .        unfavourable  effect  is  of  little  conse- 

Danger  of 

cardiac  irreg-  quence  if  the  intermissions  are  infre- 
uarity.  quent,    and    the    heart    has    a    good 

margin  of  reserve  force,  but  when  the  irregularity 
is  great,  or  the  heart  feeble,  diseased,  or  otherwise 
handicapped,  it  may  form  a  very  serious  element 
of  danger. 2  In  no  class  of  cases  is  this  danger 
more  likely  to  be  serious  than  in  cases 

Why  most 

serious  in  of  Senile  heart,  because  in  these  all 
cases  of  senile    ^\^q   elements   of  dansfer   act  in  com- 

heart. 

bination  towards  one  result  —  dilata- 
tion of  the  ventricles,  more  especially  of  the  left 
ventricle.  The  elements  of  danger  in  such  cases 
are  :  first,  the  normal,  and  still  more  any  abnormal, 
increase  in  the  aortic  blood  pressure ;  and,  second, 
any   abnormal    diminution   of    the    force    of    the 

1  Roy  and  Adami,  o|).  cit.,  pp.  293,  294,  etc. 

2  Op.  cit.,  p.  284. 


ITS  SYMPTOMS  AND   SIGNS  41 

ventricular  contractions  from  malnutrition,  or 
otherwise.  Each  of  these  conditions  prevents  the 
ventricle  from  emptying  itself,  and  increases  the 
amount  of  residual  blood  in  the  heart,  and  then 
there  comes  into  action  the  law  that  "  the  strain 
upon  the  walls  of  a  sphere  or  spheroid  increases 
with  its  circumference,  and,  therefore,  the  resist- 
ance to  contraction  of  the  heart  wall  is  increased 
whenever  it  becomes  dilated."  ^ 

Vagus  action  slows  the  heart  generally,  lessens 
the  excitability  of  the  ventricles,  and  even  when 
weak  may  reduce  the  output  from  them  by  as 
much  as  thirty  per  cent,^  thus  causing  residual 
accumulation  and  all  the  evils  that  flow  from  it. 
But  inhibitory  influences  may  pass  to  the  cardio- 
inhibitory  centre  from  every  quarter,  and  we  can 
thus  understand  how  mental  worries  or  even  phy- 
sical derangements  may,  by  a  long  continuance  of 
petty  inhibitions,  seriously  affect  the  cardiac  func- 
tion, especially  when  these  inhibitions  occur  at  a 
period  of  life  when  normal  alterations  in  structure 
tend  to  accentuate  their  evil  influence. 

Irregularity  or  intermission  should,  therefore, 
never  be  looked  upon  as  unimportant;  as  a  drop 
hollows  a  stone  non  v^,  ^ed  sceije  cadendo^  so  even  a 
simple  intermission  may  ultimately  lead  to  cardiac 

1  Roy  and  Adami,  op.  cit.,  p.  213. 

2  Op.  cit.,  p.  217. 


42  THE   SENILE  HEART 

dilatation    and   the    shortening   of    life.      I    well 

remember  an  old  gentleman  who  for 

Illustrative       ^^^^     complained  of  what  he  called  an 

case.  *^  ^ 

occasional  "dunt"  in  his  chest.  This 
"dunt,"  —  throb,  —  which  was  his  only  complaint, 
was  nothing  but  the  augmentor  impulse  following 
an  inhibition.  When  I  first  saw  him  his  heart  was 
considerably  dilated,  and  had  been  so  for  some 
time,  as  I  learned  from  his  medical  attendant. 
But  the  old  gentleman  was  quite  distinct  in  his 
statement  that  many  years  previously,  when  seen 
by  a  distinguished  consultant  in  the  west  of  Scot- 
land, the  doctor  had  told  him  that  his  heart  pre- 
sented no  sign  of  disease,  but  only  of  nervous 
derangement.  As  his  complaint  had  been  all 
along  the  same,  I  have  no  doubt  that  the  inter- 
missions existed  then,  but  that  they  had  not  as 
yet  produced  that  dilatation  which  subsequently 
resulted.  There  was  a  strong  suspicion  that  this 
patient  indulged  in  some  narcotic,  but  this  was 
never  brought  clearly  home  to  him,  and  he  never 
confessed.  He  was  somewhat  relieved  by  treat- 
ment, but  there  was  no  marked  improvement,  and 
he  was  found  dead  in  bed  not  long  subsequently, 
no  other  symptom  having  developed.  Simple  in- 
termission was  in  this  case  the  earliest  and  the  most 
persistent  symptom,  and  it  must  have  had  a  most 
important  effect  upon  the  course  of  the  disease. 


ITS  SYMPTOMS  AND   SIGNS  43 

Intermission  is  a  reflex  inhibition  of  the  heart 
through  the  vagus,  of  little  conse- 
quence in  youth,  because  the  heart  ^^'^derofin- 
has  then  a  wide  margin  of  reserve ; 
but  of  serious  import  after  middle  life,  because 
all  the  conditions  then  present  accentuate  the 
tendency  of  persistent  intermissions  to  induce 
dilatation  of  the  heart. 

The  inhibitory  cause  may  be  of  any  character 
and  may  come  from  any  quarter;    it 
may  be  physical  or  emotional,  a   dis-  mayhex>hysi- 
eased  organ,  a  depraved  secretion,  or  caioremo- 

.  tional. 

a  mental  shock.  A  violent  emotion  — 
more  especially,  strange  to  say,  if  it  be  a  joyous 
one  —  may  fatally  inhibit  the  heart's  action  ;  a  less 
violent  but  more  persistent  inhibition  lessens  the 
ventricular  output,  increases  the  residual  accumu- 
lation, and  ends  by  dilating  the  heart;  and  if  the 
exciting  cause  act  with  intensity,  and  the  heart  is 
already  enfeebled,  the  dilatation  may  be  rapid  and 
acute. 

The  shock  of  a  railway  accident  has  been  known 
to   inhibit  even   a   strong   heart,  and 

In  a  strong 

cause  it  to  intermit;    but  this   is    of  heart  the  effect 
little  consequence   in   a   young  heart  of  even  a 

poiverful  inhi- 

with  a  good  margin  of  reserve,  as  the  buion  uiti- 
effect  ultimately  dies  away.  I  have  ^f^^e^i/  ^^^^s 
known    the    intermissions    from    this 


44  THE   SENILE  HEART 

cause  to  drop  within  six  months  from  one  in 
every  two  beats  to  one  in  every  twenty,  and  I 
have  no  doubt  that  they  ultimately  ceased  alto- 
gether. 

On  the  other  hand,  I  have  known  the  shock  of 
„        ,  .^.      a  by  no  means  serious  railway  accident 

Even  a  trifling  ^  -^ 

inhiUtion  SO  to  break  down  a  commencing  senile 
may  prove        j^g^rt   as  to   make  within    a   year   an 

rapidly  J atal  '^ 

to  a  weak  infirm  and  dropsical  invalid  of  an  ac- 
tive business  man,  and  to  kill  within 
eighteen  months  a  man  who  up  to  the  time  of  the 
accident  had  scarcely  been  known  to  ail.  Yet  my 
^.  .    ,  own  experience  enables  me  to  say  with 

Time  required  ->-  J 

to  develop  di-     considerable    certainty   that    we    may 

latation  reck-  i  £  ,        i         j.      j-i  •  x 

.  reckon  irom  twelve  to  thirteen  years 

onuig  from  '^ 

the  earliest  as  the  time  required  for  the  develop- 
sij7np  om.  ment  of  serious  dilatation  in  a  middle- 
aged  man  leading  a  life  of  ordinary  activity,  but 
without  hard  work,  and  taking  no  special  care,  but 
also  having  no  special  worries,  reckoning  from  the 
time  the  patient  was  first  led  to  consult  a  physician 
on  account  of  cardiac  sjanptoms  which  were  then 
regarded  as  unimportant.  The  time  mentioned  is, 
however,  merely  approximate,  and  though  based 
upon  observation,  it  is  liable  to  many  modifications 
the  sources  of  which  are  obvious. 

I  have  spoken  of  a  railway  accident  as  a  probable 
cause  of  cardiac  inhibition,  because  in  these  days 


ITS  SYMPTOMS  AND   SIGNS  45 

such  an  accident  is  one  of  the  most  common  causes 
of  serious  shock ;  but  other  forms  of  accident  may 
be  equally  injurious,  the  result  depending  much 
more  —  in  regard  to  cardiac  disturbance  —  upon 
the  violence  of  the  attendant  emotion  than  upon 
that  of  the  physical  shock.  Thus  Richardson  nar- 
rates a  case  of  shipwreck  in  which  the  fear  of 
instant  death  from  drowning  caused  the  heart  of 
a  middle-aged  man,  in  perfect  health  and  spirits, 
suddenly  to  stop.  He  was  rescued  from  his  sink- 
ing ship  and  put  on  board  another  vessel,  and 
when  he  had  regained  sufScient  composure  he 
found  that  his  heart  intermitted  four  or  five  times 
a  minute.  At  first  these  intermissions  were  so 
disturbing  as  to  prevent  sleep;  by  and  by  they 
died  away  to  two  in  a  minute,  and  the  patient  was 
no  longer  cognizant  of  them  unless  he  felt  his 
pulse. ^  I  have  no  doubt  they  ultimately  ceased 
entirely,  but  this  is  not  recorded.  Richardson  also 
tells  us  of  another  case  in  which  wear- 

.    .       Intensity  of 

mg   anxiety  o±   purely  mental   origm  emotion  an 
developed     persistent     intermittency,  important 
followed  by  death  from  the  silent  but 
sleepless   suffering   produced,^    cardiac    dilatation 
having  doubtless  an  important  influence    on   the 
fatal  issue. 

1  Transactions  of  the  St.  Andrews  Medical  Graduates''  Asso- 
ciation, 1870,  p.  238.  2  Op.  cit.,  p.  239. 


46  THE   SENILE  HEART 

We  are  all  well  acquainted  with  the  intermis- 
sions due  to  the  gastric  irritation  arising  from 
flatulence,  undigested  food,  or  other  disturbance, 
which  are  more  prone  to  affect  those  with  long, 
narrow  chests  than  those  Avith  roomier  paunches. 
We  know  also  those  intermissions  due  to  the 
abuse  of  alcohol,  tobacco,  or  other  similar  poisons. 
Such  reflex  or  direct  inhibitions  are  fortunately 
more  easily  remedied  than  many,  but  they  are  no 
less  injurious  to  a  senile  heart,  and  they  require 
to  be  carefully  attended  to  and  their  recurrence 
prevented. 

The  following  sphygmogram  (Fig.  2)  was  taken 
from  the  radial  artery  of  a  man  whose  feeble  and 


Fig.  2. 

irregular  pulse  was  the  cause  of  considerable  anxi- 
ety to  himself  as  well  as  to  his  medical  attendant, 
especially  as  there  was  no  very  evident  reason  to 
account  for  it.  I  found  this  patient  to  be  a  man 
of  regular  and  unimpeachable  habits,  but  that  his 
health  was  considerably  below  par,  apparently 
from  confinement  during  office  hours  to  a  badly 
ventilated  apartment  in  which  a  great  deal  of  gas 
was  burned.     He  was  a  valuable  servant,  and  his 


ITS  SYMPTOMS  AND   SIGNS  47 

employers  were  quite  inclined  to  do  their  best  for 
liim ;  so  I  told  him  to  get  his  office  properly  ven- 
tilated, giving  him  at  the  same  time  a  tonic 
mixture.  The  result  was  most  satisfactory  — 
within  a  month  his  health  was  quite  re-established 
and  his  heart  steadied ;  he  has  kept  well  ever 
since,  and  conducts  successfully  the  business  of 
a  large  and  important  company. 

Here  we  had  a  young  man  (set.  36),  organically 
quite  sound,  yet  his  life  made  useless  and  miser- 
able by  a  heart  feeble,  intermitting,  and  irregular, 
because  the  blood  in  its  coronaries  was  impover- 
ished and  depraved  —  a  very  good  example  of  the 
apparent  effect  of  the  quality  of  the  blood  passing 
through  the  coronary  arteries  in  governing  the 
heart-beat.^ 

Chlorosis  and  Anaemia,  especially  that  form  of 
it  —  Hydryemia  —  where  the  blood  is  plentiful 
enough  but  of  poor  quality,  are  very  common 
causes  of  this  form  of  irregularity.  At  rest  such 
patients  have  feeble  but  regular  pulses,  but  the 
slightest  exertion  produces  one  of  two  things  — 
either  a  rapid  and  forcible  heart-beat,  or  marked 
irregularity  of  the  heart's  action.  To  maintain 
the  perfection  of  the  muscular  metabolism,  imper- 
fectly oxygenated  or  otherwise  impoverished  blood 
has  to  be  sent  through  the  heart  and  other  muscles 
1  Foster,  op.  cit,  1891,  p.  344. 


48  THE  SENILE  HEART 

much  oftener  per  minute  than  healthy  blood ;  the 
augmentor  nerve  is  therefore  called  into  action,  and 
the  heart-beat  becomes  rapid  and  forcible.  Should 
the  heart  be  fairly  well  nourished,  the  blood  not 
much  below  the  average  in  quality,  and  the  exertion 
of  but  short  duration,  this  is  all  that  happens :  the 
rapid  and  forcible  heart-beat  quiets  down  when 
the  need  for  it  ceases,  and  the  heart  is  none  the 
worse  for  its  effort.  But  when  the  heart  is  not 
so  well  nourished,  the  blood  more  depraved,  or  the 
exertion  more  sustained,  the  katabolic  action  of 
the  augmentor  nerve  becomes  dangerous  to  the 
integrity  of  the  organ  as  well  as  to  that  of  the 
organism,  and  the  anabolic  action  of 
interference  the  vagus  is  called  into  play.  The 
causes  irreg-     suffering  heart  sends  a  message  to  the 

ularity . 

inhibitory  centre,  and  the  reply  comes 
through  the  vagus  as  an  inhibition  which  weakens 
the  force  of  the  auricular  contractions,  lessens  the 
strength  of  the  rhythmic  excitation  which  reaches 
the  ventricle  from  above,  and  at  the  same  time 
diminishes  the  excitability  of  the  ventricle  itself. 

If  the  need  of  the  heart  be  urgent,  the  inhibi- 
tion is  strong,  any  stimulus  reaching  the  ventricle 
from  the  auricle  is  but  feeble,  and,  consequently, 
the  ventricle  sets  up  its  own  independent  rhyth- 
mic action.!     The  auricular  rhythm  and  the  inde- 

1  Vide  antea^  p.  40,  and  Roy  and  Adami,  op.  cit.,  p.  293,  etc. 


ITS  SYMPTOMS  AND   SIGNS 


49 


pendent  ventricular 
rhythm  are  each 
quite  regular  in 
themselves,  but 
when  they  affect 
the  ventricle  at  the 
same  time,  they  in- 
terfere with  each 
other  and  set  up 
arhythmic  irregu- 
larity .^  The  follow- 
ing sphygmograms 
are  examples  of  this 
irregularity  as  oc- 
curring in  feeble 
and  dilated  hearts. 

The  one  (Fig.  3) 
is  from  the  radial 
artery  of  a  digni- 
tary of  a  southern  university,  who 
died  within  a  year  from  the  time 
this  was  taken;  the  other  (Fig.  4) 
is  from  the  radial  of  a  man  who 
still  survives  and  is  well. 

When    the    heart    is    weak    and 
dilated,  or  the  blood  much  impov- 
erished, the  most  trifling  exertion 
1  Roy  and  Adami,  op.  cit.,  p.  283. 


Fig.  3. 


Fig.  4. 


50  THE  SENILE  HEART 

may  call  for  anabolic  action  and  give  rise  to 
arhythmic  irregularity.  But  when  heart  and  blood 
are  only  slightly  below  par,  the  violent  exertion 
of  a  foot-ball  match  may  be  needed  to  induce 
irregularity,  and  under  the  restorative  influence  of 
rest  this  speedily  dies  away. 

Very  important  information  as  to  the  condition 
of  the  myocardium,  and  the  state  of  the  blood,  is 
thus  to  be  obtained  from  the  greater  or  less  readi- 
ness with  which  irregularity  is  evoked.  The  im- 
portance of  this  in  the  prognosis  of  a  weak  heart 
need  scarcely  be  pointed  out,  and  the  value  of  a 
due  recognition  of  the  cause  of  irregularity  in 
relation  to  the  treatment  of  such  a  heart  must  be 
obvious  to  all. 

Irregularity  as  to  force  is  a  common  accompani- 
ment of  arhythmic  irregularity,  because  every  now 
and  then  the  impulse  from  the  auricle  coincides 
with  the  ventricular  systole,  and  there  is  an  unusu- 
ally full  beat,  readily  recog^nized   by 

Cause  of  ir-  "^  '  -^  . 

regularity  in  the  finger  on  the  pulse,  and  just  as 
the  force  of       easily  seen  on  the  sphygmog-ram.  This 

the  pulse.  *^        .  .f    j  &        & 

marked  irregularity  of  the  pulse-force 
constitutes  a  very  distinctive  difference  between 
the  irregularity  of  cardiac  dilatation  and  that 
which  so  frequently  accompanies  mitral  stenosis. 
In  the  former  case  a  certain  number  of  the  radial 
pulsations  are  full  and  large,  while  in  the  latter, 


ITS  SYMPTOMS  AND   SIGNS  51 

though  the  pulses  do  vary  in  force,  there  are  none 
that  can  be  called  full  or  large. 

Irregularity  in  rate,  though  not  peculiar  to  the 
senile  heart,  is  yet,  in  some  of  its  most  remark- 
able varieties,  most  commonly  found  associated 
with  it. 

These  irregularities  in  the  pulse-rate  are  inter- 
esting  and   important  enough   to   re- 

,  1,      i_  X-        x-\  Varieties  in 

quire    a    separate    chapter    to    them-   .,       , 

^  -'-  J-  the  pulse-rate. 

selves.      I   shall   only   mention   them 
at  present. 

Tremor  cordis  is  a  most  remarkable  phenomenon 
even  to  those  well  acquainted  with  it;  and  it  is 
scarcely  possible  to  conceive  anything  more  alarm- 
ing than  a  first  attack  of  what  Sir  Walter  Scott 
called  the  morbus  eruditorum^  but  which,  alas !  is 
not  nowadays  confined  to  the  erudite  any  more 
than  Podagra  is  to  the  great  and  noble,  with 
whom  Sydenham  flattered  himself  he  had  a  com- 
munity of  suffering,  and  there  is  no  one  who 
suffers  from  this  tremor  who  is  not  ready  to  ex- 
claim with  Sir  Walter :  "  What  a  detestable  feel- 
ing this  fluttering  of  the  heart  is  !  "  ^ 

Tachycardia  is  a  new  name  for  an  old  complaint 
which,  with  its  converse.  Bradycardia^  requires 
full  detail  to  make  it  either  interesting  or  under- 

1  Vide  The  Journal  of  Sir  Walter  Scott,  Vol.  i.,  p.  153. 
Douglas,  Edinburgh,  1890. 


52  THE   SENILE  HEART 

standable.  None  of  these  irregularities  in  the 
pulse-rate  are  strictly  limited  to  the  latter  half  of 
life,  but  they  are  most  common  and  most  distress- 
ing then,  and  it  is  thus  convenient,  if  not  strictly 
accurate,  to  treat  them  as  affections  of  the  senile 
heart. 

The  senile  heart  as  I  have  described  it  is  essen- 
tially a  heart  that  has  been  overstrained  through 
inability  to  do  its  work,  while  in  many  cases,  as 
just  pointed  out,  this  overstrain  or  dilatation  is 
precipitated  by  nerve  interferences.  The  degree 
to  which  the  cardiac  cavities  have  already  yielded 
we  learn  mainly  from  palpation  and  auscultation. 
In  the  hands  of  an  expert  careful  percussion  is 
capable  of  yielding  very  trustworthy 
ing  cardiac  results  in  determining  even  a  trifling 
dilatation.  increase  of  the  heart's  dulness,  but  this 
is  difficult  even  in  a  male  chest,  and  in  a  female 
one  it  is  still  more  so.  On  the  other  hand,  the  re- 
sults of  palpation  are  easily  obtained  and  readily 
comprehended ;  for  example,  when  an  individual 
over  middle  life  has  his  arteries  atherosed,  an 
accentuated  aortic  second,  a  firm,  tense  pulse,  or 
a  sphygmogram  indicative  of  high  intra-arterial 
blood  pressure,  with  his  apex  apparently  beating 
in  the  normal  position,  palpation  at  once  reveals 
whether  this  apparent  apex-beat  is  really  the  out- 
ward thrust  of  the  point  of  the  left  ventricle,  or 


ITS  SYMPTOMS  AND   SIGNS  S3 

merely  the  edge  of  the  right  ventricle.  For  the 
true  apex  of  a  normal  heart  is  the  strongest  point 
of  pulsation  in  the  cardiac  area,  whereas  the  apex 
in  a  dilated  heart  is  felt  to  be  a  mere  extension 
from  the  strongest  point  of  pulsation  lying  beneath 
the  lower  end  of  the  sternum.  At  even  an  earlier 
stage,  long  before  the  right  ventricle  has  become 
so  markedly  dilated  as  to  produce  a  pulsation  be- 
neath the  sternum  marked  enough  to  be  detected 
by  palpation,  the  ear  through  the  stethoscope  can 
readily  distinguish  the  abnormal  strength  of  the 
right  ventricular  impulse. 

The  pulmonary  circulation  being  a  closed  cir- 
cuit, whatever  hinders  the  onward  flow  of  the 
blood  through  the  left  heart,  exerts  an  equally 
obstructive  influence  on  the  flow  through  the 
right  ventricle ;  this  consequently  dilates,  and, 
as  the  right  ventricle  lies  between  the  sternum 
and  the  left  ventricle,  a  very  slight  dilatation 
suffices  to  push  the  left  apex  from  the  chest-wall 
into  the  cavity  of  the  thorax,  its  place  being  taken 
by  the  right  apex. 

As  the  heart  dilates,  the  apex-beat  extends 
gradually  outwards  to  the  left  till  it  reaches 
the  nipple  line,  or  even  beyond  it,  keeping  in 
the  fifth  interspace,  but  beating  three  or  more 
inches  from  mid-sternum  instead  of  only  two  and 
a  half. 


54  THE   SENILE  HEART 

During  the  gradual  dilatation  of  the  heart  its 

normal  sounds  undergo  a  progressive 

Changes  alteration  that  ends  in  a  loud  systolic 

which  the  ^  "^ 

heay^Vs  sounds  murmur  in  all  the  cardiac  areas.     The 
undergo  dur-     g^  ^ence  is  as  f ollows  :  — 

tng  dilatation.         ^ 

In  the  very  earliest  stage,  when  the 
sole  symptoms  are  precordial  anxiety,  a  feeble 
impulse,  and  an  accentuated  second  sound  (vide 
p.  35),  the  first  sound  is  always  more  or  less 
altered.  It  may  be  prolonged,  blunt,  feeble,  or 
impure ;  now  and  then  we  have  it  loud,  clear,  and 
booming ;  over  the  right  apex,  when  the  heart  is 
dilated,  the  first  sound  is  always  more  distinct 
than  over  the  left  apex,  except  the  booming  sound, 
which  is  a  left-side  phenomenon,  and  best  heard 
just  below  and  to  the  left  of  the  nipple.  Distinct- 
ness of  sound  is  probably  as  much  due  to  the  reso- 
nating qualities  (thinness  and  flexibility)  of  the 
chest-wall  as  to  any  particular  state  of  the  ven- 
tricle ;  the  booming  quality  conveys  to  the  mind 
the  idea  of  tension,  and  seems  to  indicate  consider- 
able dilatation  of  the  ventricular  cavity.^  Often 
accompanying  one  or  other  of  these  alterations  of 
the  first  sound,  and  certainly  speedily  following  it 

1  For  various  views  as  to  the  state  of  the  first  sound  in  dilata- 
tion of  the  heart,  vide  llo])e,  Diseases  of  the  Heart,  3d  ed.,  p.  68 
et  seq. ;  Walshe,  Diseases  of  the  Heart,  3d  ed.,  p.  315  ;  Stokes, 
Diseases  of  the  Heart,  etc.,  p.  217.  Also  Gairdner,  Ed.  Medical 
Journal,  July,  1856,  p.  55. 


ITS  SYMPTOMS  AND   SIGNS  55 

in  orderly  sequence,  the  educated  ear  has  no  diffi- 
culty in  detecting  a  systolic  murmur  in  the  auric- 
ular area,  in  appropriate  cases.  This  auricular 
murmur  is  a  murmur  audible  between  the  second 
and  third  ribs  to  the  left  of  the  sternum,  just  out- 
side the  pulmonary  area.  The  pulmonary  artery, 
as  we  know,  comes  to  the  front  between  the  second 
and  third  ribs  on  the  left  side,  one  half  of  its 
breadth  lying  beneath  the  sternum,  and  the  other  in 
the  interspace.     If  we  put  a  finger-tip 

^ ,  .  T    •     ,  1  ,       ,  1        Position  and 

m  this  second  interspace,  close  to  the  ^.^^y^^Q  ^j  ^^g 
edge  of  the  sternum,  we  cover  the  pul-  ci'UHcuiar 
monary  artery,  and  just  outside  of  the 
finger-tip  the  left  auricular  appendix  in  most  hearts 
reaches  the  chest-wall,  and  if  large  and  dilated, 
passes  to  the  front  of  the  ventricle  at  the  root  of 
the  pulmonary  artery.     The  appendix  auriculi  is 
not  always  long  enough  to  reach  the 

r»  1*1  J.1  •         Why  the 

surface,  and  m  such  a  case  the  auric-  auHcuiar 
ular  murmur   is  naturally  not   to  be  murmur  is  not 

^  111'         n  •  I'lii*      always  to  he 

heard;  but  m  all  cases  m  which  this  ^^^^^ 
murmur  is  audible  it  may  be  accepted 
as  an  early  and  infallible  sign  of  mitral  regurgi- 
tation,^ and  consequently  of  ventricular  dilatation 
in  cases  such  as  those  now  referred  to.     Failing 
this  auricular  murmur,  and  often  accompanying  it, 

1  Naunyn,   Berliner  klinische   Wochenschrift,  1868,  No.  17, 
S.  189  ;  and  Balfour,  op.  cit.,  p.  171. 


56  THE   SENILE  HEART 

we  have  as  an  early  sign  of  ventricular  dilatation, 
an  occasional  systolic  whiff  over  the 

A  transitory  ^^  . .  , ,  .  t  •  nc    •      , 

systolic  lohiff  '^Pex.  For  a  tune  this  whiff  is  tran- 
an  early  sign    sitoiy,  more  audible  at  one  time  than 

of  dilatation.         ,  , ,  ,  ^ .  ,  •      i        t 

at  another,  and  sometimes  entirely  ab- 
sent, replaced  by  a  more  or  less  altered  first  sound. 
These  variations  depend  on  the  state  of  the  circu- 
lation, the  murmur  being  always  most  distinct  after 
exertion  and  not  so  audible  —  often  entirely  absent 
—  when  the  patient  has  been  resting.  But  a  systolic 
„  murmur,  due  to  progressive  dilatation 

systolic  mur-  of  the  left  Ventricle,  does  not  long 
m?^7  spreacs.  pgj^^jj^  trifling  or  evanescent.  Ere- 
long it  is  to  be  found  whenever  listened  for ;  it  is 
speedily  followed  by  a  systolic  tricuspid  murmur, 
and  then  we  have  a  systolic  murmur  in  all  the 
cardiac  areas.  In  the  aortic  and  pulmonary  areas 
this  murmur  is  partly  due  to  propagation  from  the 
mitral  and  tricuspid  openings,  and  is  partly  pro- 
duced there,  as  an  early  phenomenon  in  the  aorta, 
and  a  late  one  in  the  pulmonary  artery,  by  the 
passage  of  the  blood  through  the  comparatively 
narrow  arterial  openings  into  the  dilated  arteries 
beyond.  By  the  time  the  mitral  and  tricuspid 
murmurs  have  developed  there  is  no  difficulty  in 
determining  from  its  enlarged  percussion  area, 
and  from  its  forcible  impulse,  that  the  heart  has 
become,  not  only  dilated,  but  also  hypertrophied. 


ITS  SYMPTOMS  AND   SIGNS  57 

The  accentuated  aortic  second  is  always  an  indi- 
cation of  a  dilatable  aorta,  but  by  itself  it  is  not 
a  sign  that  the  aorta  is  actually  dilated. 
After  death,  in  such  cases,  the  aortic  accentuated 
walls  are  always  found  to  be  inelas-  (aortic  second 

,      .  TP        ,1  J  1      indicates. 

tic ;  during  liie  the  aorta  expands 
helplessly  before  the  advancing  blood-wave,  which 
for  want  of  its  normal  elasticity  it  fails  to  pass 
completely  onwards.  The  excess  of  blood  in  the 
inelastic  ascending  aorta  falls  back  on  the  sigmoid 
valves  and  closes  them,  with  unusual  force,  by  the 
mere  virtue  of  its  abnormal  weight  (or  momen- 
tum). 

At  first,  and  for  a  time,  the  aortic  second  is 
merely  accentuated  in  virtue  of  possessing  a  louder 
and  more   distinct  sound  than  usual ;    ^, 

The  meaning 

by  and  by  there  is  superadded  a  boom-  of  a  booming 
ing  quality,  which  indicates  closure  by  ^^^^'^^• 
a  heavier  blood-column,  throwing  a  greater  tension 
on  the  aortic   valve.     As  this   tension   gradually 
increases  the   segments  of  the  valve  tend  to  get 
separated,  and  to  permit  of  regurgitation  between 
them  into  the  ventricle.     In  this   condition   any- 
thing which  diminishes  the  size  or  weight  of  the 
aortic  blood-column,  or  that  increases 
the    tone,   or  diminishes   the   extensi-   ^'^'-^^^^  «f.^^^« 

regurgitation. 

bility  of   the  aortic   walls,  diminishes 

the   regurgitant  force  of  the  blood,  and  thus  an 


58  THE   SENILE  HEART 

aortic  regurgitation  of  this  character  is  curable, 
and  is  occasionally  cured. 

Often,  however,  the  aortic  walls  are  not  merely 

inelastic   and   dilatable,  but   rigid,    atheromatous, 

and  the  lumen  dilated.     In  these  cases 

.^I'L^'mm'-    the  blood-wave  does  not  merely  dilate 

mur  in  aortic    the  passivc  walls  of  an  inelastic  aorta, 

dilatation.  ,,  .,  ,.,  i,-i  n 

but  passes  through  the  relatively  small 
aortic  opening  into  the  dilated  artery  beyond,  and 
in  so  doing  forms  fluid  veins  which  give  rise  to  a 
systolic  aortic  murmur;  an  indication  not  of  mere 
dilatability  of  the  aortic  walls,  but  of  actual  dila- 
tation of  the  aortic  lumen. 

A  merely  accentuated  aortic  second,  then,  only 
indicates  with  certainty  an  inelastic  and  dilatable 
condition  of  the  aortic  walls;  but  an  accentuated 
aortic  second,  coupled  with  a  systolic  aortic  mur- 
mur, indicates  an  actual  dilatation  of  the  aortic 
lumen,  and  this  may  be  confirmed  by  percussing 
the  aorta  and  mapping  out  its  dulness.  The 
history  of  the  case,  and  the  fact  that  diseased 
valves,  capable  of  themselves  —  by  obstructing  the 
arterial  exit  —  of  originating  a  systolic  murmur, 
are,  from  sheer  inflexibility,  incapable  of  accentu- 
ating the  second  sound,  help  to  confirm  the  diag- 
nosis. This  actually  dilated  state  of  the  aorta  is, 
much  more  often  than  a  merely  dilatable  one,  fol- 
lowed by  separation  of  the  segments  of  the  aortic 


ITS  SYMPTOMS  AND   SIGNS  59 

valve,  and  by  regurgitation  into  the  ventricle. 
Hence  it  has  long  been  known  that  in  many  cases 
—  all,  indeed,  of  this  character  —  a  systolic  aortic 
murmur  precedes  for  an  indefinite  period  the  de- 
velopment of  regurgitation.^  At  first  we  have 
only  an  occasional  diastolic  whiff  accompanying 
the  booming  second,  and  generally  to  be  earliest 
heard  at  the  sternal  end  of  the  fourth  rib  on  the 
left  side.  As  in  the  case  of  the  systolic  whiff 
in  the  mitral  area,  this  diastolic  aortic 
whiff    g-radually   becomes   permanent,     ^^^^f  ^" 

°  -^  ^  anxiety  may 

and  gets  louder  and  more  prolonged  terminate  in 
as    the    regurgitation   becomes   freer,  "^^^  °^" 

o      °  '    num. 

until  at  last  the  case  which  com- 
menced as  one  of  precordial  anxiety  with  an 
accentuated  second,  a  feeble  impulse,  and  an  im- 
pure first  sound,  terminates  as  a  cor  hovinum  with 
a  heaving  impulse,  and  a  double  murmur  more  or 
less  audible  in  all  the  cardiac  areas. 

Erelong  this  condition  is  followed  by  renal  con- 
gestion, albuminuria,  and  dropsy.     Fortunately,  all 
these    troubles    are    preventable,    and 
early  attention  to  the  beginnings  of  f^^«^^/;^^«y 

_  "^  o  o  ^g  averted. 

evil    may   not    only   avert    these   un- 
toward results,  but  promote  a  green  and  healthy 
old  age. 

No  arguments  are  required  in  the  present  day 

1  Stokes,  op.  cit. ,  p.  227. 


60  THE   SENILE  HEART 

to  prove  that  stress  of  work,  from  increase  of  the 
intra-arterial  blood  pressure,  is  sufficient  to  induce 
dilatation  of  the  heart.  It  is  acknowledged  by 
pathologists,^  and  has  been  experimentally  induced 
by  physiologists.^ 

Ventricular  dilatation  is  speedily  followed  by 
regurgitation  through  the  auriculo-ventricular 
opening,  and  this  is  now  universally  acknowl- 
edged to  be  accompanied  by  an  impure  first  sound, 
which  speedily  develo^DS  into  an  unmistakable  sys- 
tolic murmur.^  Various  explanations 
ow  regurgi-    j^g^yg  been  given  of  this  valvular  in- 

tation  IS  ° 

brought  about,  competency   without   valvular   lesion. 
re    sac-       rpj^^  explanation  which  seems  best  to 

count  of  it.  ^ 

agree  with  the  facts  is  that  given  by 
Ludolph  Krehl.  This  observer  points  out,  what 
has  indeed  been  long  known,  that  in  the  normal 
heart  the  valves  are  floated  into  apposition,  and 
the  auriculo-ventricular  opening  closed  previous 
to  the  commencement  of  the  ventricular  systole  ;  ^ 

1  Ziegler's  Pathological  Anatomy,  by  Macalister,  London, 
1884,  Part  ii.,  p.  49. 

2  Key  and  Adami,  British  Medical  Journal.,  December,  1888, 
p.  1321,  etc.,  and  Transactions  of  Boyal  Society.,  loc.  cit.,  pp. 
213  and  278,  etc. 

3  The  first  recognition  of  this  as  a  necessary  complement  of 
ventricular  dilatation,  and  not  a  mere  accidental  complication, 
we  owe  to  Dr.  Gairdner.  Vide  "The  Evolution  of  Cardiac 
Diagnosis,"  Ed.  Medical  Journal,  June,  1887,  p.  1080. 

*  Vide  Tettigrew,  "On  the  Kelations,  Structure,  and  Func- 


ITS  SYMPTOMS  AND   SIGNS  61 

were  it  otherwise,  a  manometer  within  the  auricle 
would  infallibly  indicate  regurgitation  at  the 
moment  of  systole.  When,  however,  the  ventricle 
is  dilated,  there  is  regurgitation  —  so-called  rela- 
tive insufficiency  is  established.  Not  because  the 
auriculo-ventricular  opening  is  dilated,  —  that  is 
a  later  occurrence,  —  not  because  the  segments  of 
the  valve  are  unable  to  close  the  opening,  —  one 
alone  of  these  segments  is  almost  sufficient  for  this 
purpose,  —  but  because  the  insertions  of  the  chordcB 
tendinece  into  the  papillary  muscle,  owing  to  the 
ventricular  dilatation,  are  set  so  wide  apart  and  so 
far  from  the  centre  of  the  ventricle  that  the  trifling 
pressure  of  the  auricular  blood  is  unable  to  bring 
the  valve-segments  into  apposition.^  Under  these 
circumstances  whenever  the  ventricular  systole 
commences,  regurgitation  occurs ;  at  one  time  to 
but  a  limited  amount,  at  another  to  a  greater. 

When  we  listen  over  the  apex  of  a  dilated  heart, 
we  hear  in  some  cases  only  an  impure  first  sound, 
in  others  a  systolic  whiff  precedes  a  quite  closed 
first  sound,  and  in  still  others  a  murmur  begins 
with  the  beginning  and  continues  throughout  the 
whole  of  the  systole. 

tion  of  the  Valves  of  the  Vascular  System,"  Transactions  of 
the  Boyal  Society  of  Edinburgh^  1864,  p.  799  ;  and  Physiology 
of  the  Circulation,  London,  1874,  p.  284. 

^  Vide  Archiv  fur  Anatomie  und  Physiologie,  Leipzig,  1889,. 
S.  291. 


62  THE  SENILE  HEART 

This  agrees  exactly  with  Krehl's  account;  when 
the  ventricular  systole  begins,  the  valve-segments 
are  not  in  apposition  as  they  ought  to  be ;  but  as 
the  systole  progresses  all  the  conditions  conduce 
to  the  perfect  closure  of  the  valve,  when  the  dila- 
tation is  slight.  It  is  quite  a  different  story  when 
the  dilatation  is  considerable,  or  the  valves  dis- 
eased. 

There  are  two  other  symptoms  which  are  of 
serious  import  in  advanced  life,  though  neither 
of  them  is  limited  to  that  period. 

As  an  accompaniment  of  imperfect  circulation, 
pulmonary  congestion,  or  defective  haemoglobin, 
BreatJdessness  is  the  commonest  symptom  of  car- 
diac failure  at  every  age  ;  it  is  never  absent  when 
any  exertion  is  called  for.  But  connected  with 
the  senile  heart  breathlessness  assumes  a  different 
aspect  —  exertion  is  not  needed  to  induce  it;  it 
may  occur  when  the  sufferer  is  at  perfect  rest,  and 
it  may  even  awake  him  from  sleep.  When  it 
harasses  the  patient  in  this  way,  breathlessness 
gets  the  name  of  cardiac  asthma,  and  is  often  an 
early  symptom  of  cardiac  failure.  In 
Two  forms  of   ^^-^   connection   it  is  a  true  Angina, 

Augiua. 

and  much  more  entitled  —  etymologi- 
cally  —  to  that  appellation  than  the  painful  affec- 
tion that  commonly  bears  it.  These  two  forms  of 
angina  will  be  treated  of  together,  later  on. 


CHAPTER  IV 

PALPITATION,  TREMOR   CORDIS,  TACHYCARDIA 

Palpitation  is  a  common  complaint  of  those 
who  suffer,  or  who  think  they  suffer,  from  disease 
of  the  heart.  It  is  a  term  commonly  applied  to 
all  forms  of  abnormal  cardiac  pulsations  which 
make  themselves  unpleasantly  sensible  to  the 
sufferer  —  to  intermission  as  well  as  to  irregular 
action.  Therefore,  although  palpitation  is  not  a 
symptom  peculiar  to  the  senile  heart, 

.     T       T  jv  1         What  we 

—  is,  indeed,  more  apt  to  artect  the  j^ean  hij  the 
young  than  the  aged,  —  it  is  yet  well  term ''palpi- 

tatioTit^' 

to  define  clearly  what  is  meant  by  this 

term,  so  that  it  may  be  differentiated  from  other 

forms  of  heart  hurry. 

The  distinctive  peculiarities  of  palpitation  are 
a  regular,  rapid,  and  violent  pulsation  of  the  heart, 
which  often  shakes  the  whole  chest  and  always 
makes  itself  unpleasantly  sensible  to  the  sufferer, 
accompanied  by  a  violent  throbbing  of  the  aorta, 
carotids,  and  other  large  arteries,  which  does  not 

63 


64  THE   SENILE  HEART 

extend  to  the  smaller  vessels,  the  radial  pulse 
giving  no  indication  —  in  its  force,  at  least  —  of 
the  violence  of  the  heart's  action.  Palpitation 
comes  on  suddenly,  and  may  last  from  a  few  min- 
utes to  several  hours ;  it  is  very  distressing  and 
often  alarming  to  the  sufferer,  but  it  is  not  usually 
attended  by  any  danger.  It  seems  to  be  caused 
by  reflex  inhibition  of  the  vagus  action,  a  reflex 
paralysis  of  the  inhibitory  centre  which  removes 
the  restraining  influence  of  the  vagus,  and  allows 
the  augmentors  temporarily  to  run  off  with  the 
heart.  Palpitation  occurs  in  weakly  and  ansemic 
individuals,  and  is  produced  by  reflexes  of  emo- 
tional or  gastric  origin,  never  by  exercise.  The 
rapid,  forcible  augmentor  action  that  follows  exer- 
tion in  a  spansemic  person  {vide  p.  47)  simulates, 
indeed,  palpitation  closely ;  but  in  such  a  case  the 
radials  beat  fully  and  forcibly,  the  heart's  action 
is  not  so  violent  and  throbbing,  and  all  the  phe- 
nomena cease  at  once  whenever  the  patient  be- 
comes quiescent. 

Tremor  cordis  is  a  very  remarkable  form  of 
cardiac  irregularity.  It  is  the  very  opposite  of 
palpitation.  Emotion  has  nothing  to  do  with  its 
causation,  and  the  heart,  instead  of  throbbing  as 
if  it  would  burst  the  chest-wall,  trembles  like 
an  aspen  leaf.  It  occasionally  occurs  in  youth ; 
it  is  common  enough  in  advanced  life ;  it  is  most 


PALPITATION,   TREMOR  CORDIS,   TACHYCARDIA    65 

alarming  not  only  from  its  peculiar  character,  but 
also  from  the  sudden  way  in  which  it  seizes  its 
victims.  We  talk  of  a  bolt  from  the  blue  as  the 
most  startling  thing  that  could  happen,  but  it 
could  not  be  more  startling  than  that  a  heart 
beating  quietly  and  steadily  should  suddenly  be 
seized  with  a  rapid,  tremulous  fluttering,  most 
alarming  to  the  victim  not  only  from  the  unusual 
character  of  the  sensation,  but  also  and  especially 
because  of  the  organ  affected ;  for  life  truly  seems 
slipping  away  when  the  heart  itself  trembles.  This 
affection   was    well   known   to    Senac  ^ 

Tremor  cor- 

and  the  early  physicians,  who  seem  to  dis.  Whatu 
haA^e  taken  rather  a  serious  view  of  it.  ^'^' 
These  attacks  occur  without  warning,  and  pass  off 
in  a  few  seconds,  apparently  without  detriment 
to  the  patient.  They  are  generally  spoken  of  as 
"  a  fluttering  of  the  heart,"  and  such  indeed  they 
are.  The  sensation  is  precisely  as  if  the  gouty 
twittering  of  the  muscles  spoken  of  by  Begbie  ^ 
had  affected  the  cardiac  muscle.  The  pulse  does 
not  die  away ;  it  does  not  taper  off  like  a  pulsus 
myurus^  but  it  suddenly  drops  from  the  ordinary 
full  pulse  of  health  to  a  mere  tremulous  thread. 
The  attacks  vary  from  three  or  four  sharp,  short, 
and  apparently   incomplete   systoles,  rapidly  suc- 

1  Contributions  to   Practical   Medicine,  by  James  Begbie, 
M.D.,  EdinburglL,  A.  &  C.  Black,  1862,  p.  6. 


66  THE  SENILE  HEART 

ceeding  one  another,  and  running  off  without  warn- 
ing from  a  heart  beating  regularly  and  steadily, 
up  to  a  whole  series  of  rapid,  short,  and  incomplete 
systoles,  which  may  last  for  several  seconds,  con- 
vey a  tremulous  sensation  to  the  hand  laid  over 
the  cardiac  region,  and  are  accompanied  by  a  small, 
fluttering,  and  often  scarcely  perceptible,  radial 
pulse.  This  tremor  ends  suddenly  like  an  inter- 
mission, with  an  unusually  forcible  beat,  and  from 
a  similar  cause.  During  all  those  imperfect  sys- 
toles, the  ventricle  has  been  getting  gradually 
overfilled,  the  augmentor  nerve  is  called  into  play, 
the  ventricle  forcibly  expels  its  contents,  which 
escape  freely,  and  gradually  distend  arteries  which 
have  had  time  to  get  unusually  empty.  The  heart 
then  settles  into  its  ordinary  rhythm. 

Tremor  cordis  is  not  confined  to  the  senile  heart. 
It  may  happen  at  any  age.  It  may  attack  a  heart 
apparently  healthy,  or  it  may  accompany  any  form 
of  heart  affection;  but  it  is  most  common  after 
middle  life,  and  in  hearts  which  are  feeble  and 
dilatable.  Sir  Walter  Scott  called  it  the  morbus 
eruditorum,  and  tells  us  that  in  his  youth  it  used 
to  throw  him  into  "an  involuntary  passion  of 
causeless  tears."  ^      I  myself  am  well  acquainted 

1  "  I  know,"  he  says,  "  it  is  nothing  organic,  and  that  it  is 
entirely  nervous,  but  the  sickening  effects  of  it  are  dispiriting 
to  a  degree."  —  Op.  cit.^  p.  153. 


PALPITATION,   TREMOR  CORDIS,   TACHYCARDIA    67 

with   a   man   now   getting  on   for   seventy,  who, 
at  nineteen,  was  suddenly  and  without  warning 
seized  with  a  sharp  attack  of  tremor 
cordis.     This   happened  lust  previous   <^'««e/>/tJ'emor 

^  ^  *'  ^  cordis. 

to  an  attack  of  relapsing  fever,  and, 
up  to  quite  recent  times,  it  remained  an  only  one. 
Of  late,  these  seizures  have  been  more  frequent. 
His  heart  has  always  been  irritable,  but  he  has  a 
long,  narrow  chest,  and  those  having  this  confor- 
mation have  almost  invariably  irritable  hearts. 
He  has  always  enjoyed  good  health,  but  may  be 
said  to  be  hereditarily  disposed  to  heart  affection 
on  the  mother's  side.  On  the  father's  side,  the 
deaths  have  been  for  generations,  in  the  direct  line, 
all  over  eighty,  usually  from  cerebral  apoplexy. 
Rheumatism  is  unknown  on  either  side.  Further, 
this  patient  tells  me  that  occasionally 
he  has  been  able  to  arrest  this  tremor    ^'^^^'^/«;2/  ar- 

rest  of  the 

by  a  voluntary  impulse  through  the  heart's  action. 
inhibitory  centre,  not  absolutely,  but  f^^'^J'^'"''^^^ 
markedly  enough  to  his  own  sensation. 
Nor  is  this  impossible.  There  is  one  medical  man 
recorded  by  Fothergill  as  possessing  the  power  of 
voluntarily  arresting  the  heart's  action,^  and  we 
are  all  acquainted  with  the  remarkable  case  of 
Colonel  Townsend,  narrated  by  Dr.  Cheyne  ;  ^  not 

1  Lancet,  I.,  1872,  p.  498. 

2  The  English  Malady,  by  George  Cheyne,  M.D.,  London, 
1723. 


68  THE   SENILE  HEART 

to  mention  tlie  Indian  fakeers,  who  undoubtedly 
possess  the  power  of  arresting  both  pulsation  and 
respiration,  as  we  gather  from  those  remarkable 
cases,  narrated  by  Dr.  Braid,  where  they  submitted 
to  be  buried  for  so  long  as  six  weeks  at  a  time,  till 
their  clothes  were  all  mildewed  and  rotten.^  This 
power  is  now  believed  to  be  exercised  by  voluntary 
compression  of  the  spinal  accessory  by  the  muscles 
of  the  neck,  which  transmits  a  powerful  inhibition 
to  the  heart  through  the  cardiac  branch  of  the 
vagus  with  which  the  spinal  accessory  is  so  in- 
timately connected. 

Tremor  cordis^  rare  in  youth,  common  enough 
after  middle  life,  is  always  spoken  of  as  a  flutter- 
ing of  the  heart,  and  can  generally  be  associated 
with  flatulence  or  some  other  gastric  disturbance. 
Never,  in  all  my  experience,  has  any  form  of  emo- 
tion had  any  share  in  its  causation.  Indeed,  it  is 
the  sudden  way  in  which,  without  a  thought  being 
directed  towards  it,  an  apparently  healthy  heart, 
beating  quite  regularly  and  steadily,  begins  to 
flutter  within  the  chest  that  makes  it  so  alarming 
to  the  sufferer.  No  feeling  of  faintness  seems  ever 
to  be  connected  with  this  most  uncomfortable  sen- 
sation. It  is  a  most  singular  phenomenon,  and 
difficult  to  explain  satisfactorily.     Evidently  the 

1  Observations  on  Trance^  by  James  Braid,  M.R.C.S.  Ed., 
A.  &  C.  Black,  Edinburgh,  1851. 


PALPITATION,   TREMOR  CORDIS,   TACHYCARDIA    69 

vagus  is  reflexly  inhibited,  the  heart  uncontrolled 
goes  off  at  a  gallop,  till  the  ventricle,  which  all  the 
time  has  been  gradually  getting  overfilled,  sud- 
denly invokes  augmentor  aid,  expels  its  contents 
with  a  bang,  and  at  once  settles  down  steadily 
under  normal  nervous  control.  This  explanation 
certainly  agrees  with  the  facts.  The  shorter  the 
period  of  tremor^  the  less  forcible  the  impulse  with 
which  the  heart  returns  to  work. 

Tachycaedia,  or  heart  hurry,  is  a  symptom  not 
confined  to  the  senile  heart  nor  to  the  latter  half 
of  life,  but  it  is  most  dangerous  to  the  aged,  and 
in  them  it  is  always  pathological.  In  infancy 
tachycardia  is  a  physiological  phenomenon,  as  the 
heart  of  the  new-born  babe  beats  at  the  rate  of  130 
per  minute,  gradually  dropping  to  100  at  three 
years  of  age.  In  pathological  tachycardia,  the 
heart-rate  is  said  to  reach  200  or  even  300  per 
minute.  I  myself  cannot  distinguish  with  any 
certainty  over  150  pulsations  a  minute.  By  the 
aid  of  the  sphygmograph  we  may  certainly  count 
more,  but  I  have  never  found  them  over  200. 
One  great  distinguishing  peculiarity  of  patho- 
logical tachycardia  is  the  little  disturbance  it  gives 
the  sufferer.  With  a  heart  beating  more  rapidly 
than  that  of  an  infant,  he  goes  about  his  duties  as 
unconscious  as  a  babe  of  anything  unusual.  This 
is  one  great  difference  between  tachycardia  and 


70  THE   SENILE  HEART 

palpitation,  with  which  it  is  so  apt  to  be  con- 
founded. 

During   the   first  two   years  of  life,  the  rapid 

action  of  the  heart  depends  upon  the  low  blood 

pressure,  and  concurs  with  it  in  pro- 

Normai  ^lotin^    the    diffusion    of    the    blood- 

tachycardia.  o 

plasma  and  the  rapid  growth  of   the 

tissues.  Infantile  tachycardia  is  the  necessary 
result  of  the  conditions  under  which  the  circula- 
tion is  then  carried  on ;  in  its  turn  it  is  subservient 
to  the  building  up  of  the  frame,  and  it  gradually 
ceases  as  the  intra-arterial  blood  pressure  rises  and 
development  takes  the  place  of  growth.  At  any 
later  period  of  life  tachycardia  is  an  abnormal  phe- 
nomenon, and  indicates  some  interference  with  the 
physics  of  the  circulation,  or  with  those  nervous 
connections  by  which  its  various  interdependent 
relations  are  maintained  and  regulated. 

In  a  few  cases  tachycardia  is  found  in  women  at 
the  menstrual  period,  or  during  the  puerperium; 
it  is  also  occasionally  observed  in  both  young  and 
old  recovering  from  an  illness,  their  hearts  never 
quite  falling  to  the  normal  rate,  and  by  some  all 
of  these  varieties  of  heart  hurry  have  been  looked 
on  as  physiological.  But  all  such  cases  are  excep- 
tional and  essentially  morbid  in  their  causation, 
as  are  even  those  still  rarer  cases  in  which  the 
rapid  heart  of  infancy  persists  even  to  old   age. 


PALPITATION,   TREMOR  CORDIS,   TACHYCARDIA    71 

I  am  acquainted  with  one  instance  of  this  —  a  lady, 

now  a  widow  over  seventy,  who   has    „     .  , 

•^  Persistence 

had  a  large  family,  and  whose  pulse  of  infantile 
up  to  quite  recent  years  was  never  un-  *"^  ^^^^  ^"" 
der  150  per  minute  ;  now  it  is  only  seventy.  This 
lady  is  of  a  highly  neurotic  temperament,  but  she 
has  always  enjoyed  good  health,  and  there  never 
was  any  violent  or  distressing  throbbing  either  in 
the  region  of  the  heart  or  at  the  root  of  the  neck. 

In  tachycardia  the  heart's  action  is  rapid  and 
feeble,  and  the  sounds  are  empty,  like  the  tic-tac 
of  the  foetal  heart,  while  the  radial  pulse  is  quick, 
feeble,  and  sometimes  almost  imperceptible  —  a 
state  of  matters  by  no  means  devoid  of  danger, 
and  one  which  may  terminate  suddenly  either  in 
Syncope  or  Asystole^  and  which  differs  toto  coelo 
from  other  affections  to  which,  so  far  as  the  heart- 
rate  is  concerned,  the  term  tachycardia  is  equally 
applicable. 

How  completely,  for  example,  does  the  Syn- 
drome   of    such    an    affection    differ    „     , 

bynarome  of 

from  that  of   so  notable  an  instance  exopthaimic 
of  rapid  heart  as  exopthaimic  goitre.  ^°^^^^" 
And  yet   in    Graves'   disease   there   is   often   for 
months  neither  exopthalmos  nor  goitre  —  nothing 
but  a  rapid  heart. 

There  is  always  tachycardia  so  far  as  rate  is 
concerned,   the   pulse   beating   140   or   more    per 


72  THE   SENILE  HEART 

minute  ;  but  the  heart's  action  is  violent,  and  the 
whole  arterial  system  throbs  disagreeably.  The 
heart  sounds  are  clear  and  distinct,  and  some- 
times so  loud  that  Graves,  to  whom  we  owe  the 
earliest  description  of  this  disease,  says  in  refer- 
ence to  one  of  his  cases,  "I  could  distinctly  hear 
the  heart  beating  when  my  ear  was  distant  at 
least  four  feet  from  the  chest."  ^  At  times  this 
violent  perturbative  palpitation  of  the  heart  and 
arteries  exists  alone ;  at  other  times  this  is  associ- 
ated with  goitre  only,  or  with  exopthalmos  only, 
or  all  these  three  symptoms  may  be  present ;  but 
always  and  in  every  case  the  violent  throbbing  of 
the  heart  and  arteries  is  sufficient  to  distinguish  it 
from  mere  tachycardia. 

Those  who  believe  in  an  essential  tachycardia 
^   ^       ,.       speak  of  the  heart  hurry  of  febrile  or 

Tachycardia        ^  *^ 

always  sijmp-  exhausting  diseases  as  a  symptomatic 
tomatic.  tachycardia;    and  in  like  manner  the 

rapid  pulse,  feeble  impulse,  and  empty  heart 
sounds,  which  so  often  accompany  and  herald  the 
approach  of  death,  may  with  more  reason  be  termed 
the  tachycardia  morientium^  inasmuch  as  it  is  some- 
times difficult  to  say  whether  the  tachycardia  is 
merely  the  herald  or  not  also  the  cause  of  death. 

1  A  System  of  Clinical  Medicine,  by  Robert  James  Graves, 
M.D.,  Dublin,  1843,  p.  074.  This  Lecture  was  first  published 
in  1835. 


PALPITATION,    TREMOR  CORDIS,   TACHYCARDIA    73 

For,  while  holding  that  tachycardia  is  only  a 
symptom,  it  must  still  be  acknowledged  there 
are  many  cases  in  which  it  is  the  only  detectable 
symptom.  Are  these  to  be  considered  cases  of 
true,  essential  tachycardia  or  not  ?  I  feel  certain 
that  careful  enquiry  will  in  every  such  case  dis- 
cover some  previous  heart  strain  sufficient  to 
originate  an  endocarditis  or  a  myocarditis,  some 
coexisting  chronic  disease,  some  history  of  an 
overwhelming  emotion,  or  the  abuse  of  some  car- 
diac poison,  any  one  of  which  may  be  quite  suffi- 
cient to  account  for  the  predominant  symptom. 
I  have  seen  many  cases  of  tachycardia  due  to 
heart  strain ;  many  of  these  got  well  without 
developing  any  further  symptom.  Whether  these 
were  cases  of  slight  and  evanescent  endocarditis 
or  of  myocarditis  no  one  could  say.  On  the  other 
hand,  cases  which  throughout  their  whole  course 
presented  no  other  symptom  have  terminated  in 
stenosis  of  the  mitral  opening,  as  revealed  by  all 
the  ordinary  and  well-known  signs,  and  have  thus 
sufficiently  plainly  indicated  their  endocarditic 
origin.  Never  less  than  two  years  were  required 
for  the  development  of  a  presystolic  murmur,  reck- 
oning from  the  first  appearance  of  the  tachycardia, 
and  often  much  longer. 

But  tachycardia  is  not  only,  as  it  were,  a  cause 
of  mitral  stenosis  ;  it  is  a  very  frequent  accompani- 


74  THE   SENILE  HEART 

ment  of  that  affection.     Indeed,  in  a  well-marked 

case  of  tachycardia,  I  would  look  first 
Tachycardia       „        ^,  .  t       -  ^     ^      ^  •  i 

may  termi-       for  the  Signs   01  mitral  stenosis,  and 

nate  in  mitral   fa,iling  them,  for  the  signs  of  a  dilated 

stenosis.  ,,.,.. 

heart  with  marked  indications  of  arte- 
rial atheroma.  In  the  one  case  the  heart's  action 
is  apt  to  be  not  only  quick,  but  also  irregular;  we 
have  an  accentuated  first  sound,  and  generally  a 
well-marked  pulmonary  second,  though  sometimes 

from  ansemia  this  is  not  so  well  marked 

And  is  often 

an  accompani-  as  it  ought  to  be  ;  these  signs,  coupled 

ment  of  that     -^jth  the  history  of  the  case,  enable  us 
affection. 

to  differentiate  it  from  similar  rapid 

hearts,   with,   at   all   events,   considerable    proba- 
bility. 

On  the  other  hand,  when  the  heart  is  slightly 
May  be  caused  enlarged,  dilated,  and  hypertrophied, 
by  imperfect      ^i^h  persistent    tachycardia,   there   is 

metabolism  of  .    .  •  i      i 

the  myocar-      suspicioii  01  interference  with  the  cor- 
diiim.  onary  circulation,  or  of  some  condition 

of  the  blood  involving  imperfect  metabolism  of  the 
myocardium. 

In  the  latter  half  of  life  tachycardia  is  a  symp- 
tom associated  with  various  forms  of  degeneration, 
and  if  not  from  the  first  dependent  upon  cardiac 
disease,  it  is  always  associated  with  cardiac  dilata- 
tion. From  almost  the  first,  even  in  those  cases 
which  seem  strictly  essential,  there  is  increased 


PALPITATION,   TREMOR  CORDIS,   TACHYCARDIA    75 

precordial  dulness,  dependent  on  imperfect  ventric- 
ular systole  with  residual  accumulation,  which  is 
so  essential  a  part  of  the  affection,  and  which  is 
increased  and  accentuated  by  all  those  obstacles 
to  the  onward  flow  of  the  blood  which  we  know 
to  form  so  integral  a  part  of  the  senile  changes  in 
the  circulatory  system.  Tachycardia  is  thus  not 
only,  in  many  cases,  an  important  sign  of  senile 
cardiac  degeneration,  but  is  also  in  itself  an  addi- 
tional danger  to  the  senile  heart. 

In  infancy  and  childhood  tachycardia  is  normal 
and  physiological ;  in  febrile  diseases  it  is  a  never- 
failing  symptom ;  in  anaemia  and  other 

,  Conditions  in 

states    of    exhaustion,   and    in   many  loUchtachy- 
diseases  of  the  heart  and  blood-vessels,  <^(-'^'^^'^(^  ^<^y 

be  present. 

tachycardia  is  not  an  unusual  symp- 
tom; while  the  other  conditions  with  which  this 
affection  is  found  connected  may  be  comprehended 
under  two  heads  —  intoxications  and  affections  of 
the  nervous  system. 

The  various  intoxicants,  or  poisons,  which  give 
rise  to  tachycardia,  comprise  first  of  all  —  alcohol. 

And  in  speaking  of  alcohol  as  a  cause  of  tachy- 
cardia, no  reference  is  meant  to  the  ordinary  rise 
of  pulse  that  follows  the  use,  or  still  ^;,,;,,^^,« 
more  the  temporary  abuse,  of  alcohol,  cause  of  tachy- 
but  solely  to  those  cases  of  persistent 
rapid  heart  action,  empty  heart  sounds,  and  feeble 


76  THE   SENILE  HEART 

pulse,  which  alone  constitute  the  syndrome  of 
tachycardia,  and  which  are  occasionally  found  in 
connection  with  chronic  alcoholism. 

In  such  cases  sudden  death  not  infrequently 
occurs,  and  the  heart  is  found  dilated  and  fibro- 
fattily  degenerated.  In  these  cases  the  tachy- 
cardia is  believed  to  depend  upon  a  neuritis  of  the 
vagus,  due  to  the  abuse  of  alcohol.  Such  cases 
are  always  serious,  and  are  probably  much  more 
common  than  is  as  yet  recognized.  In  some  of 
them,  and  these  the  least  serious,  the  heart  and 
pulse  are  irregular  as  well  as  rapid,  and  the  brain 
unaffected ;  in  others  the  tachycardia  either  exists 
alone,  or  it  may  accompany  delirium  tremens,  and 
it  is  then  apt  to  be  merged  in  what  appears  to  be 
the  more  serious  affection,  while  after  all  in  the 
heart  trouble  the  real  danger  lies,  the  nervous 
symptoms  being  of  comparatively  little  conse- 
quence and  quite  appeasable  by  a  twelve-hours 
sleep.  As  practitioners  we  are  so  apt  to  recognize 
a  quick  pulse  as  a  usual  accompaniment  of  the 
consumption  of  alcohol,  and  delirium  tremens  as 
a  result  that  not  uncommonly  precedes  the  end, 
that  we  are  apt  to  forget  that  the  chronic  abuse  of 
alcohol  originates  a  fibro-fatty  degeneration  of  the 
myocardium,  as  well  as  a  neuritis  of  the  vagus, 
that  the  one  impedes  the  cardiac  function,  and  the 
other  by  paralyzing  inhibition  permits  the  heart 


PALPITATION,   TREMOR  CORDIS,    TACHYCARDIA    77 

to  fly  off  in  a  hurry,  impedes  recovery,  and  duly 
recognized  may  be  acce^Dted  as  a  measure  of  the 
danger  present. 

Tea  and  coffee  used  in  moderation  increase  at 
first  both  the  force  and  frequency  of  the  heart's 
action,  and  induce  a  pleasant  excite- 
ment of   the    cerebral   functions,  but  amilofee  ^ 
the   abuse    of    these    stimulants    pro-  may  he  a 
duces  in  some  actual  intoxication,  and  tachycardia. 
in  others  that  lowering  of  the  blood 
pressure   and   acceleration   of   the    heart's   action 
which   occasionally  leads  to  an  attack    of   tachy- 
cardia, during  which  the  pulse  is  in  some  irregular. 

Tobacco  is,  however,  that  poison  most  largely 
abused  by  man,  and  from  that  abuse  we  gain  a 
large  experience.    Nicotine,  the  poison- 

^  .  Influence  of 

ous  alkaloid  of  tobacco,  at  first  slightly  tobacco  in 
slows  the  heart,   or  it  may  arrest   it  i^^oducmg 

tachycardia. 

momentarily,  causing  intermission,  or 
the  inhibition  may  be  strong  enough  to  start  the 
ventricle  on  its  own  independent  rhythm,  when 
irregularity  soon  follows  Qvide  antea,  p.  40). 
When  the  dose  is  powerful  enough  to  paralyze 
the  vagus,  the  heart  set  free  from  its  restraining 
influence  starts  off  at  a  gallop,  and  we  have  an 
attack  of  paroxysmal  tachycardia,  with  embryo- 
cardiac  sounds,  and  increased  precardiac  dulness. 
The  heart's  action  at  times   seems  tumbling  and 


78 


THE   SENILE  HEART 


irregular,  but  the  pulse  itself  is  small,  feeble,  and 
regular. 

The  following  sphygmogram  (Fig.  5)  is  an  ex- 
ample of  a  hyperdicrotous,  tachycardiac  pulse  of 


174  PER   MINUTE 


Fig.  5. 


low  tension,  beating  perfectly  regularly  at  the  rate 
of  170  per  minute,  as  reckoned  by  the  sphygmo- 
graph. 

This  patient  was  suddenly  seized  with  his  tachy- 
cardia while  playing  a  match  at  golf ;  he  thought 

of  giving  it  up,  but  a  bumper  of 
fachtardia.     whiskey  enabled  him  to  win  his  match 

with  what  must  have  been  a  perfectly 
uncountable  pulse,  as  even  when  at  rest  in  bed 
this  is  never  under  170  during  an  attack.  This 
patient  is  now  over  sixty  years  of  age,  and  during 
the  last  eight  years  he  has  had  several  similar 
seizures,  all  of  them  due  to  excessive  smoking 
coupled  with  a  good  many  nips  of  whiskey,  the 
whiskey  being  never  taken  to  excess.  I  have 
known  his  family  for  more  than  one  generation, 
and  not  one  of  them  has  ever  complained  of  the 
heart  but  himself,  and  he,  indeed,  resents  his  ail- 
ment rather  than  complains  of  it. 


PALPITATION,  TREMOR  CORDIS,   TACHYCARDIA    79 

A  rapid  heart -beat  means,  as  Donders  first 
pointed  out,  a  shortening  of  the  systole,^  a  small 
amount  of  blood  expelled  by  each  ventricular  con- 
traction, hence  shortening  of  the  primary  wave 
in  the  pulse-tracing  and  increased  depth  of  the 
dicrotic  notch,  dicrotism  of  the  pulse  and  pulse- 
tracing.  When  the  pulse-rate  is  much  increased, 
the  pulse  becomes  hyperdicrotic ;  the  ordinary 
dicrotic  notch  is  carried  on  to  the  ascending  limb 
of  the  tracing,  and  seems  to  be  anacrotic,  as  in  the 
sphygmogram  here  given.  In  this  case  there  was 
a  small,  feeble,  perfectly  regular,  but  very  rapid 
pulse  (170),  no  dicrotism  to  be  detected  by  the 
finger,  but  hyperdicrotism  very  evident  in  the  trac- 
ing. There  was  increased  precordial  dulness,  and 
a  feeble,  wobbling  heart-beat,  evidently  a  condition 
in  itself  not  devoid  of  danger  at  any  age,  and  one 
which  indicates  most  unmistakably  the  risk  to 
which  a  senile  heart  is  exposed  by  an  attack  of 
tachycardia.  Every  dicrotic  pulse  is  not  a  rapid 
one,  neither  is  every  rapid  pulse  dicrotic.  But  the 
amount  of  danger  present  in  any  case  of  tachy- 
cardia may  be  to  a  large  extent  measured  by  the 
degree  of  dicrotism  present  in  the  pulse,  as  this 
indicates  diminution  in  the  amount  of  blood  ex- 
pelled from  the  ventricle  (contraction  volume), 
increased  residual  accumulation,  and  tendency  to 
1  Nederl.  Archiv.  voor  Ge7iees-en  JSfaturk.,  Bd.  ii.,  1865,  S.  184. 


80  THE   SENILE  HEART 

death  from  failure  of  the  heart  —  sudden  or  in- 
gravescent asystole. 

In  sudden   death  from   cardiac  failure  there  is 

failure    of  the   heart   to    contract,  failure   of  the 

,     ,  ,  heart  to  respond  to  the   call   of   the 

Asystole  may  •*- 

he  sudden  or  katabolic  nervc — Asystole.  At  times, 
ingravescent.  j^Q^ever,  the  failure  to  contract  is  not 
sudden  and  complete,  but  occupies  an  appreciable 
period  of  time,  from  a  few  moments  to  a  few  days, 
or  even  longer,  and  it  is  then  most  appropriately 
termed  Ingravescent  asystole. 

In  neither  of  these  forms  of  asystole  is  there 
any  feeling  of  f aintness  —  only  a  sensation  of  im- 
pending dissolution,  and  a  gradual  failure  of  both 
pulse  and  heart,  the  act  of  dying  occupying  but  a 
few  minutes,  and  the  mind  remaining  clear  to  the 
last.i 

When  the  asystole  is  of  longer  duration,  the 
pulse  is  small,  feeble,  quick,  and  sometimes  irreg- 
ular ;  the  heart's  action  is  rapid,  feeble,  sometimes 
wobbly ;  the  liver  and  spleen  are  congested,  and 
if  dying  is  prolonged,  they  may  enlarge.  There  is 
oedema  of  both  lungs,  or  oedema  of  one  lung  and 
effusion  into  the  other  pleura;  there  is  often 
slight  blood-spitting,  from  general  pulmonary  con- 
gestion or  from  local  patches  of  pulmonary  apo- 
plexy due  to  thromboses ;  the  oedema  of  the  lung 
1  Balfour,  op.  cit.,  p.  305. 


PALPITATION,   TREMOR  CORDIS,   TACHYCARDIA    81 

is  sometimes  so  great  as  to  make  the  part  affected 
seem  solid,  yet  this  solid  oedema  may  disappear 
in  a  few  hours,  or  it  may  shift  its  place  when  the 
position  of  the  body  is  changed;  there  is  slight 
oedema  of  the  feet  and  ankles,  with  a  slowly 
increasing  soakage  of  all  the  tissues,  a  trace  of 
albumen  in  the  urine,  which  slowly  increases,  and 
a  duskiness  of  the  skin,  which  deepens  as  death 
approaches,  and  is  most  noticeable  at  the  finger 
tips  and  nails.  As  a  rule  there  is  no  recovery 
from  this  condition,  though  death  may  be  linger- 
ing. This,  however,  depends  of  course  upon  the 
inducing  cause ;  in  olden  times,  when  aconite  was 
looked  upon  as  the  equivalent  of  digitalis,  I  have 
seen  hearts  brought  into  a  state  of  almost  fatal 
asystole  by  the  one  drug,  quickly  and  rapidly 
restored  to  health  by  the  other.  Most  usually 
this  ingravescent  asystole  is  a  terminal  phenome- 
non, and  death  long  prepared  for  comes  often 
unexpectedly  at  the  last,  the  ingravescent  asystole 
suddenly  becomes  complete. 

Sundry  medicinal  agents  also  produce  tachy- 
cardia when  given  in  poisonous  doses.  Digitalis^ 
for  instance,  when  given  in  too  large  doses,  or 
in  doses  too  closely  approximated,  paralyzes  the 
vagus  and  sets  free  from  control  the  heart's  idio- 
motor  mechanism.  If  this  paralysis  comes  on 
slowly,  we  have,  first,  a  slow  pulse  with  an  occa- 

G 


82  THE   SENILE  HEART 

sional  quick  beat;  by  and  by  the  pulse  becomes 
quick  with  an  occasional  slow  beat,  or  an  inter- 
mission;  and  finally,  when  the  regulating  power 
is  entirely  lost,  the  intermissions  disappear,  and  the 
pulse  becomes  regular  but  very  rapid,  the  heart's 
sounds  are  embryocardiac,  —  reduced  to  a  mere 
tic-tac,  —  the  arterioles  are  dilated,  and  the  blood 
pressure  low. 

Belladonna  and  Atropine  in  moderate  doses  in- 
crease the  quickness,  fulness,  and  force 
How  digitalis,  ^£  ^^^  pulse ;   they  also  increase  the 

belladonna,  ^  ^ 

and  atropine  blood  pressure.  In  toxic  doses  both 
induce  tachy-    ^^  these  drugs  paralyze  the  vagus,  the 

heart  runs  off,  and  the  pulse  becomes 
extremely  rapid,  feeble,  and  often  irregular. 

Reflex  tachycardia  is  generally  of  short  dura- 
tion, and  is  rarely  attended  by  any  danger.     Reflex 

tachycardia  is  usually  accompanied  by 
Reflex  tachy-     Q^her  neurotic  symptoms,  such  as  dila- 

cardia,  its  ''      ^ 

symptoms.        tation  of  the  pupils,  flushing  of  the 

How  they  are      ^  f^^   ^f   j^^^^  ^^l   OVCr   the  body, 

produced.  ^  _  *' 

or  outbreaks  of  perspiration,  local  or 
general.  These  symptoms  certainly  indicate  reflex 
action  through  the  sympathetic  system,  but  we 
must  not,  therefore,  conclude  that  the  tachycardia 
itself  is  produced  by  action  on  the  accelerators 
alone,  though  there  are  certain  other  symptoms 
which  seem  also  to  point  to  this  conclusion.     For 


PALPITATION,   TREMOR  CORDIS,   TACHYCARDIA    83 

example,  we  find  in  reflex  tachycardia  that  the 
heart's  impulse  is  forcible  and  the  pulse  full,  in- 
stead of  both  being  feeble  and  the  pulse  small,  as 
in  ordinary  tachycardia  due  to  vagus  inhibition. 
But  we  must  not  forget  that  the  same  thing  also 
happens  occasionally  in  tobacco  poisoning,  in  which 
the  heart  hurry  is  undoubtedly  due  to  vagus  inhi- 
bition. In  fact,  remembering  the  trifling  results, 
so  far  as  tachycardia  is  concerned,  which  follow 
excitement  of  the  accelerators  alone,  and  also  the 
fact  that  certain  causes  of  reflex  tachycardia  do 
in  other  circumstances  act  as  vagus  inhibitors,  the 
conclusion  is  forced  upon  us  that  in  certain  cir- 
cumstances, not  yet  clearly  understood,  the  same 
cause  that  inhibits  the  vagus  also  excites  the 
augmentors,  so  that  we  have  at  one  and  the  same 
time  an  idiomotor  tachycardia  from  vagus  inhibi- 
tion, and  a  forcible  heart-beat  and  a  full  radial 
pulse  from  excitation  of  the  augmentors.  In  ordi- 
nary circumstances  the  vagus  acts  as  the  pendulum 
of  a  clock  —  it  regulates  the  motion ;  when  its 
action  is  inhibited,  it  is  as  if  the  pendulum  were 
removed,    and  the   idiomotor    mecha- 

Diference  be- 

nism   of   the    clock  allowed  to  rattle   tv^een  simple 
on  at  an  uncountable  rate.     This  is  (^nd  reflex 

tachycardia. 

tachycardia    pure    and    simple.      But 
when   the   pendulum   is    only  shortened,  not   re- 
moved, the  rate  indeed  is  quickened,  but  consider- 


84  THE   SENILE  HEART 

able  force  of  beat  remains ;  this  is  reflex  tachy- 
cardia. 

There  is  nothing  abnormal  either  of  neurotic  or 
organic  origin  which  may  not  act  as  an  excitant 
to  an  attack  of  tachycardia.  Every  kind  of  emo- 
tion or  psychical  impression ;  all  sorts  of  neuroses, 
hysteria,  epilepsy,  neurasthenia;  every  form  of 
dyspepsia ;  affections  of  the  liver,  only  rarely ; 
floating  kidneys ;  prostatic  disease ;  abdominal 
tumours,  intestinal  worms ;  various  forms  of  neu- 
ralgia ;  also  uterine  affections  of  divers  characters, 
—  may  all  at  times  prove  the  exciting  causes  of 
paroxysms  of  heart  hurry  of  shorter  or  longer 
duration,  and  in  women  these  are  most  prone  to 
occur  during  amenorrhoea  and  at  the  menopause. 
Affections  of  the  lungs,  and  especially  of  the 
heart,  are  also  well-known  causes  of  tachycardia ; 
and  when  the  heart  affection  is  a  mitral  stenosis, 
the  heart  hurry  often  persists  for  many  years 
apparently  without  any  serious  detriment  to  the 
patient. 

Whatever  may  be  the  exciting  cause  of  the 
attack,  there  is  no  doubt  that  any  breakdown  in 
the  general  health,  any  anaemia  that  may  be 
present,  whether  from  increased  haemolysis  or  de- 
fective hsemogenesis,  is  a  most  powerful  predis- 
posing cause,  especially  if  conjoined  with  that 
gouty  venosity  always  present  after  middle  life. 


PALPITATION,   TREMOR  CORDIS,   TACHYCARDIA    85 

Tachycardia  of  purely  emotional  origin  is  often 
very  persistent  in  its  duration.  In  the  case  of  a 
middle-aged  lady  in  whom  the  attack  was  brought 
on  by  severe  mental  emotion  of  some  duration 
culminating  in  a  tragedy,  it  persisted  for  years, 
ultimately  dying  quite  away.  In  this  case  the 
tachycardia  was  followed  by  a  threatening  of  sym- 
metrical gangrene  of  the  finger-tips,  which  also 
was  perfectly  recovered  from.^ 

Antecedent   sources    of    emotion    are    common 
enough  causes  of  tachycardia,  but  the  connection 
is  not  always  very  obvious  to  the  suf-   y,^^^  ^^^^^^  ^^ 
ferer,  and  in  all  the  complaints  made  emotional 

,,       I  l^     ,    lA  j_    •  tachycardia. 

it  usually  happens  that  the  most  im- 
portant is  never  touched  upon  at  all.     In  the  case 
just  referred  to,  the  patient  was  almost  well  before 
the  source  of  her  sufferings  was  ascertained. 

The  following  case  was  of  a  similar  character. 
This  patient,  a  clergyman,  consulted  me  several 

1  Raynaud's  disease  —  another  neurotic  affection,  of  which 
this  is  the  single  instance  out  of  many  observed  that  showed 
any  affinity  to  tachycardia.  Symmetrical  gangrene  is  more 
allied  to  those  curious  vaso-motor  affections  in  which  there  is  a 
persistent  feeling  of  coldness,  either  local  or  general,  which  it 
is  difficult  to  remove  or  even  alleviate.  The  coldness  seems  to 
be  due  to  actual  constriction  of  the  vessels.  One  of  my  patients 
died  during  the  winter  of  what  might  be  termed  a  universal  chil- 
blain. A  feeling  of  local  coldness,  as  well  as  pain,  frequently 
precedes,  generally  accompanies,  and  is  apt  to  follow  even  a 
threatening  of  vaso-motor  gangrene. 


86  THE   SENILE  HEART 

years  ago  for  rapid,  irregular  action,  affecting  a 
heart  somewliat  dilated  and  also  hypertrophied. 
The  trifling  irregularity  soon  disappeared,  and  a 
spell  of  tachycardia  set  in  that  lasted,  with  some 
remissions,  for  a  period  of  nearly  four  years.  Dur- 
ing all  this  time  the  pulse  was  continuously  ex- 
tremely rapid  and  feeble,  the  heart's  impulse  weak, 
and  its  sounds  embryocardiac  in  character.  With 
my  finger  on  this  feeble,  rapid  pulse,  I  have  often 
felt  it  run  off  into  a  scarcely  perceptible  tremor,  — 
pulsus  myurus^  —  and  while  wondering  whether  it 
would  ever  return,  it  would  suddenly  come  back 
with  a  feeble  thump  and  continue  on  as  before, 
the  patient  remarking,  "  That  was  one  of  my 
peculiar  attacks,"  but  never  sajdng  that  he  felt 
faint.  Indeed,  one  of  the  most  remarkable  facts 
connected  with  this  case  was,  that  with  a  pulse  so 
rapid  —  never  under  130  —  and  feeble,  there  was 
so  little  uneasiness  or  distress,  and  that  the  patient 
was  able  to  go  about  very  much  as  usual.  Under 
appropriate  treatment,  coupled  with  several  months' 
relief  from  duty,  he  was  so  far  restored  that  at  the 
end  of  two  years  he  felt  himself  able  to  accept  the 
most  dignified  position  which  his  Church  had  in 
its  power  to  bestow.  And  I  may  add  that  he  dis- 
charged the  somewhat  onerous  duties  of  this  posi- 
tion not  only  with  dignity  and  ability,  but  to  the 
entire  satisfaction  of  his  friends  and  of  his  Church. 


PALPITATION,   TREMOR  CORDIS,   TACHYCARDIA    87 

Nearly  two  years  subsequently  he  died  from  an 
attack  of  pneumonia,  the  result  of  exposure  to 
cold  after  exertion  in  early  spring,  having  been 
wonderfully  free  from  heart  symptoms  for  some 
time  previously.  Indeed,  the  heart,  being  slightly 
hypertrophied,  was  not  specially  at  fault  at  the 
last,  though  more  than  sixty  years'  service  and  all 
it  had  come  through  had  not  tended  to  improve  its 
power  of  resistance. 

The  remarkable  part  of  the  case  is  this :  that 
here  we  had  a  perfectly  healthy  man,  leading  a 
model  life,  and  doing  only  the  ordinary  work  of 
a  country  clergyman,  which  few  would  consider 
either  hard  or  excessive,  suddenly  struck  down 
with  a  serious  attack  of  tachycardia  engrafted 
upon  a  dilated  and  hypertrophied  heart.  There 
was  an  entire  absence  of  all  the  usual  causes  of 
enlargement  of  the  heart.  There  was  no  disease 
of  the  valves,  no  marked  arterio-sclerosis,  and 
therefore  presumably  no  affection  of  the  coronaries. 
There  was  no  affection  of  the  lungs  or  kidneys, 
nor  had  there  been  any  undue  exertion.  The 
patient  was  well  developed,  and  had  reached  ad- 
vanced age  in  perfect  health,  so  there  was  no 
reason  to  suspect  abnormal  narrowness  of  the 
aorta.  Further,  he  was  a  most  temperate  man,  so 
excess  of  any  kind  could  not  be  alleged  as  a  cause, 
and,  so  far  as  I  could  learn,  there  was  no  reason 


88  THE   SENILE   HEART 

to  suspect  any  hereditary  tendency.^  But  he  was 
over  sixty,  and  the  vascular  changes  which  age 
brings  on  every  one  must  have  considerably  pro- 
gressed, when  he  was  suddenly  assailed  by  the 
most  terrible  bereavement  which  can  befall  any 
man.  Then  he  began  to  age  rapidly,  and  eighteen 
months  subsequently  he  consulted  me  with  the 
symptoms  already  described.  Evidently  the  heart 
labouring,  as  all  hearts  do  more  or  less  under  the 
strain  thrown  upon  it  by  the  loss  of  arterial  elas- 
ticity, had  its  contractility  impaired  by  the  inhib- 
itory emotional  influence  conveyed  to  it  through 
the  vagus.  It  must  also  at  thi^  time  have  suffered 
somewhat  from  impaired  nutrition,  and  all  these 
circumstances  must  have  combined  to  produce  the 
dilatation  which  was  speedily  followed  by  slight 
hypertrophy. 

The  heart  hurry  in  this  case  did  not  die  off 
in  a  few  weeks  or  months,  as  is  commonly  the 
case  in  attacks  of  paroxysmal  tachycardia,  but 
persisted  for  years ;  and  this  we  can  scarcely 
wonder  at  when  we  remember  that  the  cause 
was  not  only  a  powerful,  but  a  persistent,  emo- 
tion. 

1  Vide  Traube,  Gesammelte  Beitrdge  zur  Pathologie  und 
Fhysiologie,  Berlin,  1878-0  ;  Striimpell,  Lehrhuch  der  Speciellen 
Pathologie  und  Therapie,  Leipzig,  1883,  Erster  Band,  S.  422  ; 
and  Oscar  Fraeutzel,  Die  idiopathische  Herzvergrosserungen, 
Berlin,  1889. 


PALPITATION,   TREMOR  CORDIS,   TACHYCARDIA    89 

This  case  is  instructive  as  showing,  in  the  first 
place,  how  efficient  a  cause  of  cardiac  enlargement 
the  mere  natural  loss  of  arterial  elasticity  is,  even 
in  those  who  are  perfectly  healthy  and  temperate. 
Just  the  other  day  I  saw  an  old  gentleman  of 
eighty-two ;  in  all  his  long  life  he  had  never  ailed. 
He  was  of  most  temperate,  almost  abstemious, 
habits  ;  up  to  a  few  months  ago  he  thought  noth- 
ing of  walking  five  or  six  miles  over  a  rough,  hilly 
road,  and  was  never  breathless.  I  saw  him  for 
breathlessness  due  to  pulmonary  congestion  fol- 
lowing influenza,  and,  to  my  astonishment,  found 
his  heart  dilated  and  hypertrophied,  beating  with 
a  heaving,  forcible  impulse  in  the  fifth  interspace, 
considerably  to  the  left  of  the  nipple.  As  I  had 
known  this  gentleman  all  my  life,  the  condition  of 
his  heart  was  quite  a  revelation  to  me,  and  a  very 
remarkable  proof  of  the  efficiency  of  natural  causes 
in  giving  rise  to  cardiac  enlargement,  which  in  his 
case,  even  more  than  in  most,  seemed  to  deserve 
the  adjective  "idiopathic."  The  key  to  this  case, 
as  well  as  to  all  similar  cases,  lies  in  the  structural 
change  of  the  senile  arteries,  and  in  the  fact  that 
all  such  hearts  are  not  simply  hypertrophied,  but 
are  dilated  and  hypertrophied.  Even  Cohnheim 
has  said  that  "  the  great  majority  of  all  idiopathic 
cardiac  hypertroj^hies  are  eccentric,"  and  that 
"  non-eccentric  hypertrophy  has  chiefly  a  theoretic 


90  THE   SENILE  HEART 

interest,"  ^  —  a  statement  that  might  be  even  more 
strongly  emphasized. 

In  the  second  place,  this  case  is  interesting  as 
showing  how  readily  the  erethism  of  a  weak  and 
labouring  heart  may  pass  into  alarming,  if  not 
actually  serious,  tachycardia,  under  the  influence 
of  an  overwhelming  emotion. 

And,  lastly,  this  case  furnishes  a  most  remark- 
able example  of  the  small  amount  of  actual 
suffering  entailed  by  even  a  most  severe  attack 
of  tachycardia,  and  how  wonderfully  little  the 
habits  of  life  may  sometimes  be  disturbed  by  Avhat 
seems  even  to  an  expert  to  be  a  most  serious  car- 
diac affection. 

To  conclude,  as  vagus  inhibition  is  the  great 
cause  of  tachycardia,  intra-thoracic  tumours,  often 
of  no  great  size,  pressing  upon  or  involving  the 
vagus  in  their  structure,  are  well-known  causes 
of  persistent  heart  hurry,  not  simply  paroxysmal, 
but  fatal. 

'^Lectures  on  General  Pathology^  New  Sydenham  Society's 
Translation,  London,  1869,  Vol.  i.,  pp.  70,  71. 


CHAPTER  y 

BRADYCARDIA   AND   DELIRIUM   CORDIS 

Laennec,  the  earliest  of  auscultators,  has  said, 
"  We  can  distinguish  two  kinds  of  intermissions : 
the  one  real^  consisting  in  an  actual  suspension  of 
the  heart's  contractions ;  the  other /aZse,  depending 
on  contractions  so  feeble  as  to  be  imperceptible,  or 
almost  imperceptible,  to  the  touch  in  the  arteries."  ^ 
And  Hope  has  supplemented  this  by  stating  that 
"  when  one  or  two  beats  are  regularly  and  perma- 
nently imperceptible  in  the  pulse,  such  cases  con- 
stitute the  bulk  of  those  in  which  the  pulse  is 
described  by  non-auscultators  as  being  singularly 
slow  —  for  instance,  thirty  or  twenty  per  minute." 
And  he  adds,  "In  a  few  rare  cases,  however,  it  is 
really  slow."  ^  So  far  as  my  own  experience  goes 
the  rarity  has  been  all  the  other  way,  as  I  have 
seen  many  more  really  slow  hearts,  than  hearts 

1  A  Treatise  on  the  Diseases  of  the  Chest,  and  on  3Iediate 
Auscultation,  translated  by  Joliii  Forbes,  M.D.,  2d  edition, 
London,  1827,  p.  570. 

2  On  Diseases  of  the  Heart,  3d  edition,  London,  1839,  p.  377. 

91 


92  THE   SENILE  HEART 

beating  at  the  normal  rate  with  an  abnormally  slow 
pulse,  due  to  alternate  hemi-systoles. 

Slow  i)ulse  ^  *^ 

fromhemi-  There  is  never  any  difficulty  in  mak- 
systo  e.  ^^^  ^  diagnosis  between  the  two  varie- 

ties of  slow  pulse ;  we  have  but  to  count  heart 
and  pulse  together  to  realize  that  in  the  one 
class  of  cases  each  heart-beat,  few  and  far  between, 
is  followed  by  a  distinct  pulse  at  the  wrist,  while 
in  the  other  set  a  varying  number  of  cardiac  pulsa- 
tions never  reach  the  periphery.  Sometimes  every 
alternate  beat  is  dropped,  and  at  others  two  or 
more. 

The  first  case  of  this  kind  that  came  before  me 

was  that  of  an  old  lady  with  a  gouty  history,  but 

who  had  never  had  a  regular  attack. 

Case  of  false     ^j^^  ^^^^  suddenly  seized,  while  shop- 

hradycardia.  '^  ^ 

ping,  with  what  seemed  to  be  an  epi- 
leptic fit.  In  spite  of  what  was  supposed  to  be 
appropriate  treatment,  these  seizures  continued  to 
recur  whenever  she  made  the  slightest  exertion, 
and  when  I  saw  her  she  was  unable  to  rise  from 
the  recumbent  position  without  bringing  on  an 
epileptiform  attack.  Upon  examination,  I  found 
her  pulse  beating  only  20  per  minute,  while  her 
heart  was  beating  at  the  rate  of  60;  only  every 
third  beat  was  strong  enough  to  reach  the  periph- 
ery. The  heart  was  dilated,  with  a  feeble  impulse, 
but  without  any  murmur;  the  aortic  second  was 


BRADYCARDIA   AND  DELIRIUM   CORDIS         93 

accentuated.  Remembering  Stokes'  admirable 
essay  on  the  connection  of  pseudo-apoplectic 
attacks  with  the  feeble  circulation  that  he  believed 
to  depend  upon  fatty  degeneration  of  the  heart,^ 
there  was  no  difficulty  in  connecting  the  epilepti- 
form seizures  with  the  state  of  the  heart,  and  just 
as  little  difficulty  in  determining  upon  the  appro- 
priate treatment.  The  result  was  most  satisfac- 
tory—  the  old  lady,  who  had  been  looked  upon 
as  the  victim  of  serious  senile  epilepsy,  had  no 
more  attacks.  Within  a  week  she  was  able  to 
entertain  some  friends  at  dinner,  and  she  lived  for 
several  years  without  any  recurrence  of  her  serious 
symptoms,  dying  gradually  at  last  from  asthenia. 

Hearts,  however,  which  are  really  slow  belong 
to  quite  a  different  and  a  much  more  serious  cate- 
gory. Several  years  ago  I  received  the  following 
letter  from  a  professional  friend :  "  A  medical 
man  in  this  neighbourhood,  in  extensive  first-class 
practice,  knowing  that  I  had  been  your  resident 
physician,  asked  me  to  examine  his  heart.  What 
rather  troubled  him  and  made  him 
think  of  his  health  was,  that  formerly  f«^^^/^7.« 

^     bradycardia. 

his  pulse  was  alwaj^s  60,  and  that  now 

it  is  invariably  48,  except  sometimes  after  dinner, 

^  Dublin  Quarterly  Journal  of  Medical  Science,  Vol.  xi.,  1846  ; 
also  Diseases  of  the  Heart  and  Aorta,  Dublin,  1884,  pp.  322, 
362,  etc. 


94  THE  SENILE  HEART 

if  he  has  taken  a  little  champagne,  when  it  reaches 
60  again.  He  has  arcus  senilis  (age  53)  well- 
marked,  but  nothing  remarkable  in  the  radial  or 
temporal  arteries,  and  is  as  active  and  energetic 
as  possible.  Lately  I  have  noticed  that  he  often 
looked  tired  and  worn  out,  but  he  says  he  is  not 
overworked.  I  carefully  examined  the  heart,  and 
found  nothing  except  feeble  apex-beat  and  sounds. 
His  temperature  does  not,  as  a  rule,  come  up  to 
98°.  I  tell  you  this,  because  Sir  William  Jenner 
told  him  that  he  had  noticed  that  men  with  a  slow 
pulse  and  rather  low  temperature  live  a  long  time. 
This  gentleman  does  not  feel  at  all  ill,  but  is 
anxious  to  know  whether  his  slow  pulse  (so  much 
slower  than  formerly)  ought  to  be  looked  upon 
as  indicating  degenerative  changes  in  the  heart 
and  vessels ;  and  if  so,  whether  it  would  be  wiser 
to  knock  off  some  of  his  work,  which  he  can  easily 
afford  to  do."  My  reply  to  this  was,  that  the  signs 
and  symptoms  detailed  were  evident  indications 
of  cardiac  failure ;  that  the  heart,  so  far  as  my 
experience  could  enable  me  to  judge  without  a 
personal  interview,  was  beginning  to  dilate,  that 
the  arteries  liad  undoubtedly  lost  their  elasticity, 
and  were  probably  even  more  atheromatous  than 
was  suspected.  I  advised  considerable  lessening 
of  his  dail}^  work,  and  indicated  the  lines  upon 
which  the  treatment  should  be  conducted.     This 


BRADYCARDIA   AND  DELIRIUM   CORDIS         95 

patient  acted  as  advised;  he  survived  for  nearly 
nine  years,  and  was  then  found  dead  in  bed  one 
morning  when  on  a  yachting  tour. 

A  pulse  of  48  is,  of  course,  only  abnormally  slow 
in  relation  to  the  normal  pulse  of  the  individual, 
because,  though  70  to  75  may  be  reckoned  the 
normal  pulse  of  most,  there  are  some  whose  pulse 
never  rises  above  60,  and  a  few  —  a  very  few  — 
whose  normal  pulse  is  never  even  up  to  48,  and 
who  yet  enjoy  perfect  health.  Haller  tells  of  two 
people  whose  radial  arteries  did  not  beat  oftener 
than  from  24  to  30  times  a  minute ;  and  M.  Roux 
relates  the  case  of  an  agriculturalist  who  had  gone 
through  his  military  service  without  difficult}^, 
who  never  had  a  complaint  either  cardiac  or  cere- 
bral, and  who  was  a  typical  example  of  good 
health,  and  yet  his  pulse-rate  was  never  over  34 
to  40  per  minute,  and  even  a  run  of  several  min- 
utes never  raised  it  higher  than  from  50  to  bb^ 
and  that  only  for  a  few  seconds.^  Several  similar 
cases  have  been  recorded,  the  most  remarkable 
and  best  known  being  that  of  the  great  Napoleon, 
whose  pulse,  according  to  Corvisart,  was  only  40 
per  minute.  Napoleon  is  often  cited  as  an  ex- 
ample of  a  slow  pulse  combined  with  perfect 
health ;  but  Napoleon  was  an  epileptic,  like  many 

1  Vide  "  Le  pouls  lent  permanent."  Par  le  docteur  E. 
Leflaive.     Gazette  des  Hapitaux,  1891,  p.  1072. 


96  THE   SENILE  HEART 

—  if  not  most  —  of  the  sufferers  from  brady- 
cardia. 

Slow  pulses  are  rarely  to  be  found  in  early  life, 
but  occasionally  they  are  found  even  at  so  early 
Bradycardia  ^^  ^^^  ^^  five  years;  some  of  these 
may  he  physi-  youthf ul  cases  are  apparently  phys- 
0  ogiea .  iological   and    attended   with    perfect 

health,  but  the  larger  number  at  any  age  are 
strictly  pathological,  not  only  in  their  origin, 
but  also  and  specially  in  their  results.  Rare  at 
all  ages,  bradycardia  increases  in  frequency  and 
danger  after  middle  life,  and  is  more  common 
among  men  than  women.  All  the  cases  I  have 
seen  have  been  men. 

The  earlier  observers  —  Adams,^  Richard  Quain,^ 
and  Stokes  ^  —  endeavoured  to  connect  sequen- 
tially a  slow  heart  with  fatty  des^en- 

But  is  most  .  . 

frequently  cration  of  the  myocardium.  Indeed, 
pathological      ^]^g  ^q^q  survivor  of  thcsc  three  still 

and  senile. 

quotes  slowness  of  the  pulse  as  a 
symptom  of  this  affection,  acknowledging  at  the 
same  time  that  quickening  of  the  pulse  increasing 
with  age  may  also  be  an  important  indication  of 
the  same   pathological  condition.*     But  the  very 

1  Dublin  Hospital  Eeports,  Vol.  iv.,  1827. 

2  Medico- Chirurgical  Transactions,  Vol.  xxxiii.,  p.  162. 

3  Op.  cit.,  p.  326. 

*  Dictionary  of  Medicine,  p.  595,  1882. 


BRADYCARDIA   AND   DELIRIUM  CORDIS         97 

antagonism  of  the  two   symptoms   precludes  the 
idea  of  the  connection  of  either  with  ^.^aycardia 
a   fatty   myocardium   being   anything  notaresuitof 
but  purely  accidental.     Indeed,  a  simi-  '^'J^^^^  nor  of 
lar  statement  may  be  made  in  regard  any  other  car- 

.  ,^  ,  T  i?   J.1       T-        1.     diac  lesion. 

to  atheromatous  disease  oi  the  heart, 
aorta,  or  coronaries,  as  well  as  all  other  cardiac 
and  vascular  affections  with  which  a  slow  pulse 
has  been  incidentally  found  connected.  These 
lesions  are  all  so  much  more  frequently  found 
apart  from  a  slow  pulse  than  with  it,  that  it  seems 
much  more  reasonable  to  conclude  that  the  appar- 
ent connection  is  merely  accidental,  than  that 
there  is  any  direct  relation  of  the  one  to  the 
other.  This  is  quite  distinctly  the  case  even  in 
regard  to  the  only  lesion  which  is  always  present 
in  every  case  of  senile  Bradycardia  —  dilatation 
and  hypertrophy,  the  dilatation  predominating. 
Slow  pulses  are  rare,  but  after  middle  life  dilata- 
tion and  hypertrophy  of  the  heart  are  of  every- 
day occurrence. 

Inhibitory  impulses,  we  know,  pass  through  the 
inhibitory  centre  down  the  vagus  to  the  heart; 
these  slow  the  heart  and  diminish  its  excitability. 
Roy  and  Adami  tell  us  that  there  is  a  limit  to  this 
slowing,  and  that  after  a  longer  or  shorter  period 
the  ventricles  start  off  on  an  independent  rhythm 
of  their  own  (vide  antea^  p.  39).     Accident,  how- 


H 


98  THE   SENILE  HEART 

ever,  frequently  carries  out  experiments  which  are 
more  suggestive  and  often  more  fruitful  than  any 
contrived  by  art,  and  this  seems  to  be  specially 
true  in  relation  to  the  causation  of  slow  pulse. 

Surgical  observers  have  long  since  recognized 

that  fracture  of  the  cervical  vertebra,  especially 

of  the  fifth  or  sixth,  frequently  gfives 

Relation  of  .  '         u  j   & 

injury  of  the  ^isc  to  slow  pulsc.  Gurlt  says  that 
cervical  cord     fractures  cvcn  as  low  down  as  the  first 

to  sloiv  inilse. 

dorsal  vertebra  may  have  this  result, 
and  that  the  pulse  may  fall  as  low  as  36  or  even 
20  per  minute ;  ^  and  Charcot  states  that  retarda- 
tion of  the  pulse  is  one  of  the  most  interesting 
and  least  noticed  facts  of  the  symptomatology  of 
cervical  spinal  lesion.^ 

Jonathan  Hutchinson  tells  us  that  unless  injury 
to  the  spine  is  in  the  cervical  region,  no  influence 
on  the  heart's  action  is  ever  observed.  But  he 
states  that  if  the  fracture  is  high  up,  the  cardiac 
pulsations  are  greatly  diminished  in  frequency, 
while  (from  the  paralysis  of  the  artery)  the  pulse 
itself  is  remarkably  full  and  large.  He  adds 
that  it  is  very  remarkable  to  see  a  man  scream- 
ing  with   pain   and   obviously   suffering   acutely, 

1  Handhuch  der  Lehre  von  den  Knochenbruchen,  1864. 

'^  Lectures  on  the  Diseases  of  the  Nervous  System,  by  J.  M. 
Charcot,  New  Sydenham  Society's  Translation,  London,  1881, 
p.  117. 


BRADYCARDIA   AND  DELIRIUM   CORDIS         99 

with  a  full,  slow  pulse,  beating  not  over  48  per 
minute.^ 

Rosenthal  has  recorded  the  case  of  a  girl  of  fif- 
teen who  received  a  blow  on  the  region  of  the  sixth 
cervical  vertebra.  This  was  followed  by  symptoms 
of  slight  and  quite  transitory  cerebral  shock,  ac- 
companied by  hemiplegia  of  the  right  side,  which 
did  not  last  longer  than  twenty-four  hours.  But 
for  four  weeks  subsequent  to  the  injury,  the  pupil 
(presumably  the  right,  but  which  is  not  stated) 
remained  dilated,  and  the  cardiac  pulsations  oscil- 
lated between  56  and  48.  The  patient  recovered 
completely.^ 

This  fact  of  slow  pulse  following  injury  to  the 
cervical  cord,  and  passing  off  when  that  injury  is 
recovered  from,  may,  I  think,  be  very  instructively 
considered  in  connection  with  Holberton's  well- 
known  case,  in  which  the  injury  to  the  cervical 
cord  was  not  direct,  but  the  result  of  inflammatory 
action,  and  in  which  it  took  two  years  to  develop 
retardation  of  the  pulse. 

This  gentleman,  aged  sixty-four,  was  thrown  on 
his  head  in  the  hunting-field  in  December,  1834. 
At  first  he  was  stiff  and  sore,  with  great  pain  in 
the  neck,  about  the  cuneiform  process  and  the 
condyles  of  the  os  occipitis.     The  pain  continued 

1  London  Hospital  Beports,  1866,  p.  366. 

2  Charcot,  o}:).  cit.,  p.  117, 


100  THE   SENILE  HEART 

about  six  weeks.  At  the  end  of  a  year,  he  was 
well,  in  excellent  spirits,  but  still  complaining  of 
a  difficulty  in  moving  his  head. 

In  January,  1837,  he  had  a  fainting  fit  when  out 
walking,  and  the  medical  man  who  attended  found 
his  pulse  to  be  only  20  in  the  minute.  His  usual 
pulse  was  now  found  to  be  33,  but  often  during  a 
fit  it  fell  to  20,  15,  or  8  in  the  minute,  and  even 
when  not  in  a  fit,  it  was  occasionally  as  low  as  7J 
per  minute.  His  syncopal  attacks  always  ended 
in  epileptiform  seizures,  and  as  time  went  on,  they 
increased  in  frequency  as  well  as  in  severity.  His 
first  alarming  succession  of  fits  occurred  in  June, 
1838,  and  his  last  and  fatal  attack  was  in  April, 
1840.  After  death  his  heart  was  found  to  be  en- 
larged, the  walls  of  the  left  ventricle  were  rather 
thin,  the  valves  healthy,  the  auriculo-ventricular 
opening  dilated.  No  ossification  or  calcareous  de- 
posit was  found  in  any  part  of  the  vascular  system. 
The  inflammatory  action  which  had  followed  the 
injury  to  the  first  and  second  vertebrae  had  nar- 
rowed the  foramen  magnum  and  upper  part  of  the 
spinal  canal,  compressing  and  increasing  the  density 
of  the  medulla  oblongata  and  upper  part  of  the 
spinal  cord.  This  gentleman  never  had  any  par- 
alysis, never  after  the  first  few  weeks  suffered  pain 
in  the  neck.  His  spirits  when  free  from  attacks 
were  excellent,  and  his  general  health  often  very 


BRADYCARDIA   AND  DELIRIUM   CORDIS       101 

good.  During  the  last  three  or  four  years  of  his 
life  he  was  liable  to  cold  feet,  and  suffered  from  a 
feeling  of  general  chilliness.^ 

These  cases  which  so  markedly  connect  slight 
and  transient  injury  (concussion)  of  the  cervical 
cord  with  temporary  slowness  of  the  pulse,  and 
more  serious  and  permanent  injury  of  the  same 
part  of  the  cord  with  permanent  slowness  of  the 
pulse,  leave  no  room  for  doubt  that  through  this 
centre  it  is  possible  to  convey  to  the  heart  an 
inhibitory  influence,  powerful  enough  to  bring  its 
pulsations  down  to  7|-  beats  per  minute,  and  per- 
sistent enough  to  last  for  many  years. 

Roy  and  Adami  tell  us  that  vagus  inhibition 
may  arrest  ventricular  action  altogether 

Diif&T&ncB  &6- 

for  a  short  period,  but  that  it  does  not  tv^een  vagus 
persistently   slow   the    heart,   because   o.nd  cervical 

inhibition  • 

sooner  or  later  a  time  arrives  when 
vagus  inhibition  is  set  at  naught,  and  the  ventricles 
start  off  on  a  rhythm  of  their  own,  an  idio-ven- 
tricular  rhythm  ^  (^vide  antea,  p.  39).  But  cer- 
vical inhibition,  as  we  may  call  it,  is  not  only  strong 
enough  to  force  a  slow  rhythm  upon  the  heart,  but 
is  also  powerful  enough  to  compel   the  heart  to 

1  "A  case  of  slow  pulse  with,  fainting  fits,  which  first  came 
on  two  years  after  an  injury  to  the  neck  from  a  fall."  By 
T.  H.  Holberton,  Medico- Chirurgical  Transactions,  London, 
1841,  p.  76. 

2  Op.  cit.,  p.  233. 


102  THE   SENILE  HEART 

keep  to  this  slow  rhythm  for  years,  with  but  tri- 
fling variations.  For  years  the  heart  may  pulsate 
at  the  rate  of  20,  30,  or  40  beats  per  minute,  with- 
out ever  quickening  its  pace,  without  an  inter- 
mission, or  even  a  hint  at  irregularity.  It  seems 
as  if  the  whole  heart,  sinus,  auricle,  and  ventricle, 
were  forcibly  controlled  and  compelled  to  keep 
steadily  to  the  unnatural  rhythm.  Now  and  then, 
as  in  Holberton's  case,  we  have  an  occasional  in- 
termission. Still  more  rarely  we  have  a  bout  of 
irregularity  interposed,  as  in  a  most  interesting 
case  which  I  shall  presently  relate.  But  as  a  rule, 
the  steady,  slow,  funereal  beat  never  varies  from 
the  time  it  commences  till  the  patient's  death. 

If  we  ask  why  the  cervical  cord  should  have  so 

potent  an  influence  upon  the  heart,  there  seems  to 

be  but  one  possible  answer:  Because 

Region  of  cer-    ,.  ,  i  •      ? 

vicai  cardiac  f^om  this  region  the  spi7ial  accessory 
iniuhitionis      arises.     This    nerve    rises   by   several 

that  from 

which  the  roots,  beginning  as  low  down  as  the 
spinal  acces-     sixth   ccrvical   vertebra ;    it    runs   up 

son/  arises. 

within  the  spinal  canal  through  the 
foramen  magnum  into  the  cranial  cavity,  and 
thence  it  passes  out  through  the  foramen  lacerum 
posterius  in  close  proximity  to  the  vagus.  The 
internal  portion  of  the  spinal  accessory  subse- 
quently joins  the  vagus  and  is  distributed  to  the 
heart,  presumably  as  its  motor  nerve.     The  vagus 


BRADYCARDIA   AND  DELIRIUM  CORDIS       103 

and  the  nervus  accessorius  resemble  a  spinal  nerve, 
tlie  vagus  Avith  its  ganglion  being  the  posterior  or 
sensitive  root,  while  the  spinal  accessory  is  the 
anterior  or  motor  root.  Concussion  of  the  cord 
at  the  origin  of  the  spinal  accessory  produces  tem- 
porary slowness  of  the  pulse  ;  severe  injury  to  that 
part  of  the  cord,  disease  of  the  cervical  mem- 
branes, or  of  those  at  the  base  of  the  brain  (pachy- 
meningitis), involving  injury  or  compression  of 
the  accessory  nerve,  produces  permanent  slowness 
of  the  pulse.  Besides  these  direct  injuries  there 
are  various  reflexes  and  several  poisons  which  are 
supposed  to  have  a  retarding  influence  upon  the 
heart.  The  Indian  fakeers,  it  is  alleged,  slow  the 
heart  and  diminish  the  force  of  its  beat  by  volun- 
tary compression  of  the  muscular  branches  of  the 
nervus  accessorius  in  the  neck  (^vide  antea,  p.  67). 
Various  cases  of  slow  pulse  have  been  recorded 
in  connection  with  abscess  of  the  brain ;  gastric 
irritation  and  constipation  often  precipitate  the 
syncopal  attacks,  and  by  some  have  been  supposed 
to  be  the  only  exciting  cause.  In  one  of  mj  own 
cases  alcoholic  excess  was  the  only  pos-  ^^^^^.^  .,.^.^^. 
sible  cause  that  could  be  discovered.  tio7i  and  con- 

Txn       j_       5  J-       Ji      ^  ^  •     rt     1.         •  stipation  great 

Holberton  s  patient  had  his  first  serious  ^^,-^^^^^(^1^^ 
attack  the  day  following  a  heavy  din-  ofsijncopai 

1  XT  11       i_  1      cell    attacrCS- 

ner,  when,  as  Holberton  says,  he  "  had 

eaten  heartily  of   a   variety  of   substances,"   and 


10+  THE   SENILE  HEART 

with  him  both  gastric  irritation  and  constipation 
were  found  to  be  serious  provocatives  of  syncopal 
attacks,  and  they  always  affected  the  pulse-rate, 
either  raising  it  or  lowering  it,  and,  strange  to  say, 
the  one  was  as  liable  as  the  other  to  be  followed 
by  an  attack.  Burnett  also  records  a  case  of  slow 
pulse  with  epileptiform  seizures,  in  which  the  only 
discoverable  cause  was  disturbance  of  the  chy- 
lopoietic  viscera ;  and  he  quotes  two  similar  cases 
from  Morgagni,  in  which  no  other  cause  could 
be  discovered.  In  Burnett's  own  case  the  pulse 
ranged  from  14  to  28,  though  it  occasionally  rose 
to  56.1 

Several  of  my  patients  have   died  in  syncopal 

attacks,  but  I  myself  have  never  seen  such  a  seiz- 

.     ure.     Holberton  describes  a  fit  as  al- 

Character  of 

a  syncopal  ways  preceded  by  cessation  of  the 
attack.  pulse  for  a  second  or  two  before  syn- 

cope took  place ;  on  the  heart  recommencing  to 
beat,  "  the  face  would  redden,  and  consciousness 
return  with  a  wild  stare  and  occasionally  a  snort- 
ing, a  slight  foaming  at  the  mouth,  and  a  convul- 
sive action  of  the  muscles  of  the  mouth  and 
face."  2 

The  initiatory  seizure  seems  thus  to  be  essen- 

1  "  Cases  of  Epilepsy  attended  with  Remarkable  Slowness  of 
the  raise,"  by  William  Burnett,  M.D,,  Medico-cMriirgical 
Transactions^  1827,  p.  202.  2  j^qq^^  qh^^  p.  79. 


BRADYCARDIA   AND   DELIRIUM   CORDIS       105 

tially  syncopal  in  character,  while  the  succeeding 
phenomena  are  evidently  due  to  the  unusually 
large  blood-wave  with  which  the  tissues  are  sud- 
denly flushed  on  what  may  be  termed  the  return 
of  life. 

But  however   effectual    affections  of   the   chy- 
lopoietic  viscera  may  be  in  the  production  of  syn- 
copal attacks  when  a  slow  pulse  already  ^^  ^  x  A  ar^ 
exists,  the  numbers  of  disturbed  stom-  retardation 
achs  and  constipated  bowels  that  are     ^^  ''^ ' 
found  apart  from   any  retardation   of  the   pulse, 
make  it  extremely  doubtful  —  to  say  the  least  of 
it  —  whether  of  themselves  these  conditions  have 
any  material  effect  in  slowing  the  pulse.     And  the 
same  remark  may  be  made  in  regard  to  all  those 
reflexes  to  which  retardation  of  the  pulse  has  been 
assigned  as  a  symptom.     More    definite   informa- 
tion as  to  this  is  still  a  desideratum. 

We  know  that  many  poisons,  both  organic  and 
inorganic,  bile,  ursemia,  diphtheria,  digitalis,  lead, 
etc.,  slow  the  heart,  but  these  all  have 

Retardation 

a  direct  action  upon  the  nerves,  and  of  the  pulse 
upon   the  nerve-centres. ^     Indeed,  all  p^^^^^^v  «^- 

-*■  _  wa^js  due  to 

the  information  at  present  at  our  com-  direct  action 
mand  seems  to  point  to  direct  action  ^^^  ^^^^  nervus 
on  the  spinal  accessory  in  the  neck  or 


accessorms. 


1  Greenliow  mentions  a  remarkable  case  of  slow  pulse  with 
paralysis  following  diplitlieria,  in  which  the  large  nerves  of  the 


106  THE   SENILE  HEART 

chest,  before  or  after  its  junction  with  the  vagus, 
whether  by  concussion,  compression,  or  otherwise, 
as  undeniably  the  most  potent,  and  probably  the 
only  cause  of  abnormal  or  pathological  brady- 
cardia. 

Hemi-systole  has  already  been  mentioned  as  a 
cause  of  apparent  slowness  of  the  pulse,  because 
only  every  second  or  third  beat  is  strong  enough 
to  reach  the  periphery.  The  following  sphygmo- 
gram  represents   this    condition.     In  it   (Fig.   6) 


Fig.  6. 

the  pulse  is  seen  to  rise  at  once  to  its  full  height ; 
the  secondary  dicrotic  wave  occupies  its  usual 
position,  but  lower  down  the  descending  limb  — 
just  where  in  a  normal  tracing  the  elevation  of  a 
new  pulse  ought  to  begin  —  there  is  a  slight  ele- 
vation {a)  due  to  the  hemi-systole,  imperceptible 
to  touch  and  not  always  to  be  found  in  the  tracing. 
In  true  bradycardia  the  sphygmogram  is  per- 
fectly different.  In  it  (Fig.  7)  there  is  what 
appears   to   be   a   great  round-topped   pre  dicrotic 

limbs  were  painful  to  touch ;  the  natural  inference  is  that  prob- 
ably the  spinal  accessory  was  similarly  affected.  Recovery  was 
complete.  —  Lancet^  1872,  Vol.  i.,  p.  615. 


BRADYCARDIA   AND  DELIRIUM   CORDIS       107 

blood-wave,  as  if  the  blood  pressure  was  greatly 
increased,  or  as  if  the  rigid  arterial  wall  was  only 
slowly  raised  by  the  advancing  blood- wave. 


32  PER  MINUTE 


Fig.  7. 


The  true  explanation  is  as  follows :  So  long  as 
the  circulation  remains  intact,  the  heart 
s^ets   more    distended   the   long^er  the  ^^P^f^^f^'^ 

°  ^  of  a  orady- 

diastole  is  prolonged.    At  each  systole  cardiac 
a    larg^er    blood- wave    than    usual    is  ^^y^^- 

°  gram. 

thrown  out,  and  as  the  arteries  have 
had  a  longer  time  than  usual  to  empty  themselves, 
it  passes  rapidly  onwards,  and  as  can  be  readily 
understood,  the  secondary  dicrotic  wave  is  not 
only  of  greater  amplitude  than  usual,  but  it  also 
occurs  earlier  on  the  descending  limb.  In  the 
sphygmogram  (Fig.  7)  the  point  A  marks  the 
height  of  the  pulse-wave.  The  round  top  follow- 
ing is  not,  as  might  be  supposed,  the  pulse-wave 
itself,  but  is  really  the  secondary  or  dicrotic  wave 
placed  near  the  upper  part  of  the  descending  limb 
instead  of  about  its  middle.  In  some  sphygmo- 
grams,  this  dicrotic  wave  is  so  ample  and  so 
premature  that  it  appears  to  occupy  the  very  sum- 
mit of  the  wave,  the  true  apex  of  the  pulse-wave 


108  THE   SENILE  HEART 

lying  below  it,  so  that  the  tracing  has  an  anacrotic 
appearance. 

The  large  blood-wave  sent  on  is  naturally  asso- 
ciated with  a  temporary  rise  of  blood  pressure, 
which  rapidly  dies  off  through  the  continuous  out- 
flow through  the  arterioles  during  the  prolonged 
diastole.  Hence  in  bradycardia  we  have,  as  in 
aortic  regurgitation,  an  abnormally  high  blood 
pressure  alternating  with  an  exceptionally  low  one. 
A  knowledge  of  this  explains  much  that  seems 
anomalous  in  the  history  of  bradycardia,  and  it 
has  also  a  not  unimportant  bearing  on  the  treat- 
ment of  such  cases. 

In  the  sphygmogram  (Fig.  7),  the  pulse-rate  was 
32,  but  it  varied  from  36  to  28,  and  in  this  patient, 
as  in  all  the  senile  brady cardiac  hearts  I  have  ever 
„    .,   ^    ,      seen,  there   was   marked  dilatation  of 

Senile  brady- 
cardia prob-      the  heart,  extension  of  the  precordial 
ably  always      ^^1^-,^^^    apex-beat   to   the  left   of  its 

associated  ^ 

with  cardiac     usual  position,  and  always  a  mitral  mur- 

dilatation.  n  x   t 

mur  —  generally  a  systolic  murmur  — 
in  all  the  areas.  Knowing  as  we  do  the  very  high 
blood  pressure  the  heart  has  to  cope  with  shortly 
after  the  commencement  of  systole,  the  fact  that 
most  of  these  slow  hearts  belong  to  the  latter  half 
of  life,  and  that  the  heart,  in  common  with  the  other 
tissues  suffers  in  its  nutrition  from  the  extremely 
low  blood  pressure  prevailing  during  diastole,  and 


BRADYCARDIA   AND  DELIRIUM  CORDIS       109 

suffers  most  just  when  it  is  called  upon  to  make 
its  greatest  exertion,  we  cannot  wonder  that  such 
hearts  are  always  dilated.  They  also  hypertrophy 
—  never  much,  but  a  little  — ■  quite  sufficient  to 
enable  them  to  carry  on  the  circulation.  I  have 
never  seen  any  reason  to  regard  the  myocardium 
of  these  slow  hearts  as  specially  feeble,  —  rather  the 
reverse.  But  sufferers  from  senile  bradycardia  are 
generally  sluggish  and  inert,  which  is  perhaps  not 
to  be  wondered  at. 

About  a  dozen  years  ago  I  received  the  following 
letter :  "  In  autumn,  1875,  after  a  time 
of  much  anxiety,  I  fell  down  and  was  J^^^J^J 

•^  oradycardia. 

unconscious  for  two  minutes,  with  a 
very  slow  pulse.  At  various  times  after  that,  in 
1877  and  in  1878,  I  had  turns  of  faintness,  ac- 
companied by  great  slowing  of  the  pulse,  which 
resumed  its  natural  pace  when  the  faintness  wore 
off.  In  November,  1879,  the  pulse  got  down  to  a 
steady  slowness  of  36  per  minute.  A  course  of 
quinine  and  iron  was  tried  without  any  good  effect. 
My  friend,  Dr.  Dobie,  of  Chester,  then  prescribed 
for  me,  and  after  about  six  weeks,  about  the  mid- 
dle of  February,  the  pulse  was  suddenly  restored 
from  36  to  70,  and  continued  at  its  usual  rate  all 
March,  but  in  April  it  fell  gradually  back  to  36, 
keeping  remarkably  steady  at  that  figure.  Occa- 
sionally, for  a  few  minutes  at  a  time,  it  rose  to  40 


no  THE  SENILE  HEART 

or  fell  to  28,  but  it  speedily  returned  to  36  as  its 
normal  rate,  which  it  has  ever  since  maintained. 
During  June  and  July,  I  again  tried  Dr.  Dobie's 
prescription,  but  without  any  good  effect.  In 
August  I  went  to  Harrogate,  and  by  Dr.  Myrtle's 
advice  took  Kissingen  water.  At  the  end  of  a 
week  he  supplemented  this  with  chloride  of  iron 
water.  At  the  end  of  another  week  I  had  become 
rapidly  weak,  and  Dr.  Myrtle  ordered  me  to  abandon 
this  prescription.  Since  then  I  have  abandoned 
all  treatment,  and  continue  very  weak.  This  da}^, 
at  early  morning,  my  pulse  was  30 ;  while  I  write 
it  is  36." 

This  letter  was  speedily  followed  by  a  personal 
visit  from  the  patient  himself,  and  I  find,  from 
notes  taken  at  the  time,  that  he  had  a  weak  dilated 
heart,  with  a  loud  systolic  mitral  and  tricuspid 
murmur;  pulse  ranging  from  36  to  40;  no  albu- 
minuria. He  made  but  little  progress  while  under 
observation,  the  pulse  still  continuing  slow,  and  he 
was  lost  sight  of  in  a  few  months.  Being  lately 
— 1890  —  desirous  of  ascertaining  the  result,  I  put 
myself  in  communication  with  the  patient's  friends, 
and  received  from  himself  the  following  letter : 

"  I  seem  to  have  sent  you  an  account  of  my  ill- 
ness in  1880,  so  I  need  not  notice  it  previous  to 
that  date. 

"  During  the  years  1881,  '82,  and  '83,  the  pulse 


BRADYCARDIA   AND  DELIRIUM  CORDIS       111 

continued  from  30  to  34,  accompanied  by  great 
exhaustion.  During  these  years  I  gave  up  all 
treatment  of  any  kind,  living  in  my  usual  way, 
without  any  medical  advice  whatever. 

"About  the  end  of  November,  1883,  I  was 
amusing  myself  with  a  little  grandson  from  India, 
and  had  a  good  deal  of  laughing  and  fun  with 
him.  A  change  seemed  to  have  come  upon  the 
long  dreary  tramp  of  30,  with  its  solemn  regular- 
ity; it  had  now  become  of  the  most  irregular 
character,  ranging  from  30  to  80.  A  strong  beat, 
then  five  or  six  very  small  ones  all  in  a  rabble, 
like  the  bursting  of  a  wooden  barrier  across  a 
river,  with  masses  of  the  debris  gathering  again 
and  obstructing  the  current  for  a  time,  and  then 
bursting  through  again.  At  the  end  of  about  a 
week  the  irregularity  ceased,  and  at  the  end  of 
1883  it  was  moving  quite  naturally  at  70. 

"  This  improved  state  of  things  continued  for 
several  months,  when  it  began  again  to  slow  down 
to  the  thirties,  where  it  has  continued  ever  since  ; 
the  highest  record  of  this  period  being  about  36, 
and  the  lowest,  28.  One  peculiar  feature  of  this 
slow  pulse  is  its  regularity;  in  some  conditions 
36  can  be  depended  upon,  in  some  34,  and  in 
some  32.  It  does  not  often  come  below  this, 
although  28  has  been  recorded  several  times. 
While  I  write  my  pulse  is  perfectly  steady  at  36. 


112  THE   SENILE  HEART 

I  have  been  much  troubled  with  sleeplessness, 
caused  by  twitching  or  flickering  of  the  legs, 
accompanied  by  great  depression  of  spirits ;  but 
in  another  three  months  I  shall,  if  spared,  have 
lived  the  threescore  and  ten,  which  most  people 
admit  is  quite  long  enough.  I  always  looked  well, 
having  a  very  florid  complexion,  with  a  good  deal 
of  blue,  however,  in  it.  I  have  not  fallen  down 
again  to  be  insensible  as  I  was  at  the  first,  but 
have  been  glad  to  stretch  myself  out  on  the  road 
sometimes,  so  as  to  avoid  what  appeared  to  be 
a  fainting  turn  coming  on." 

This  patient  died  two  years  subsequently  in  a 
syncopal  attack,  his  heart  having  been  irregular 
for  some  time  previously,  in  this  way :  that  for 
one  while  the  beats  were  very  slow,  and  again, 
for  another  while,  faster,  but  always  slow.  There 
was  no  examination  of  the  body. 

I  am  not  aware  of  any  other  case  of  true  brady- 
cardia in  which  marked  irregularity  was  even  an 
occasional  phenomenon,  but  to  my  knowledge 
there  is  no  other  recorded  experience  of  the  effect 
of  unwonted  exertion  on  a  heart  of  this  character. 

The  effect  so  graphically  described  seems  to 
have  been  the  result  of  the  unwonted  exertion 
forcing  the  ventricles  into  an  independent  rhythm. 
When  the  systole  of  that  independent  ventricular 
rhythm  happened  to  coincide  with  the  systole  of 


BRADYCARDIA   AND  DELIRIUM   CORDIS       113 

the  auricle,  then  there  was  the  occasional  "  strong 
beat "  referred  to ;  while  the  "  rabble  "  of  five  or 
six  small  beats  were  the  result  of  ventricular 
systoles  which  did  not  coincide  with  any  auricular 
systole. 

While   delirium  cordis  of  this  character  is  an 
unusual  symptom  in  true  bradycardia,  it  is  by  no 
means    uncommon    in   gouty,   dilated 
hearts,  at   least  as  a  temporary  phe-     ®  ^!^^^°^ 

'  jr  J     jr  cordis. 

nomenon.  It  is  always  desirable  in 
all  such  cases  to  make  a  careful  comparison 
between  heart  and  pulse,  and  if  possible  to  take 
a  sphygmogram  of  the  latter.  Delirium  cordis 
is  common  enough  in  mitral  stenosis,  but  in  that 
affection  it  is  never  so  striking  a  phenomenon  as 
in  the  dilated  gouty  heart.  Because  in  stenosis  — 
unless  the  stenosis  is  very  slight  —  the  difference 
between  the  size  of  the  beats  is  never  so  marked 
as  when  the  auriculo- ventricular  opening  is  at 
least  of  the  normal  size.  Less  frequently  this 
delirium  cordis  in  the  gouty  heart  is  found  to  be 
constantly  present,  never  ceasing  from  its  first 
appearance  till  death  occurs.  Of  my  own  personal 
knowledge  I  can  only  recall  three  such  cases,  all 
of  them  well-marked  examples.  Two  of  these 
were  well-known  professional  men,  who  both  died 
from  dilated  hearts  —  one  at  the  age  of  threescore 
and   ten,  and   the   other   twenty  years   younger. 


114  THE   SENILE  HEART 

The  elder  of  these  had  the  pulse  of  delirium  cordis 
for  twenty  years  before  his  death,  of  my  own 
knowledge.  I  doubt  if  the  younger  man  suffered 
for  longer  than  about  five  years,  and  both  con- 
tinued to  work  till  close  upon  the  end  with  the 
utmost  calmness  and  self-possession.  The  only 
other  example  of  well-marked  and  persistent  deli- 
rium cordis  I  can  now  recall  was  an  old  lady 
shown  to  me  as  a  clinical  curiosity,  who  lived  in 
the  heart  of  Westmoreland,  and  did  not  seem  in 
the  least  disturbed  by  her  unusual  condition,  of 
which  she  was  yet  fully  conscious. 


CHAPTER  VI 

ANGINA  PECTOEIS 

According  to  Quain  80  per  cent  of  all  cases 
of  angina  pectoris  occur  after  the  fortieth  year  of 
life ;  there  can  be,  therefore,  no  hesi- 
tation  in  regarding  it  as  a  symptom  risasymp- 
of   the  senile  heart.     Yet  even  when  torn  of  the 
childhood  is  scarcely  passed  life  may 
be  cut  short  with  this  symptom,  and  it  is  equally 
certain   that  death  may  then  occur  from  causes 
usually  regarded   as   purely  senile   in    character. 
Tortuous,     hard,     and     atheromatous 

Yet  death 

arteries    are  not  uncommon   in   early  from  angina 
life,  and  Dr.  Wild  of  Manchester  has  ^^«^^  ««^'^^ 

vjhen  child- 

recorded   the  sudden  death  of  a  girl  hood  is 
of   twelve  with  advanced  sclerosis  of  scarce??/ 

passed. 

the    coronary  arteries.^    She  was   not 
known  to  have  suffered  from  angina,  but  there 
is  such  a  thing  as  angina  sine  dolore^  and  sudden 
death  with  such  a  lesion,  and  without  other  evi- 
dent cause,  may  very  fairly  be  attributed  to  this. 

1  The  Manchester  3Iedical  Chronicle,  July,  1892,  p.  230. 

115 


116  THE   SENILE  HEART 

Wild  has  also  recorded  the  sudden  death  of  a 
girl  of  nineteen  from  angina,^  and  I  myself  have 
published  a  case  of  death  from  angina  at  the  early 
age  of  twenty-four.2  ]s^q  g^gg  ^.^^  therefore  be 
looked  upon  as  necessarily  free  from  lesions  usu- 
ally found  in  advanced  life,  nor  is  any  period  of 
life  always  exempt  from  symptoms  commonly 
found  in  connection  with  senile  lesions. 

The  term  "  pseudo-angina  "  is  often  applied  to 
anginous  pains  occurring  before  middle  life,  espe- 
cially in  the  female  sex,  and  yet  we 
Angina  a         ^^^  ^^^^^  fatal  ansfina  may  occur  in  one 

symptom  ^  "^ 

which  may  who  is  still  but  a  girl.  To  talk  of 
occur  at  any  pgeudo-angina  is,  however,  a  mark  of 
ignorance  rather  than  of  refinement 
of  diagnosis ;  for  angina  is  but  a  symptom,  and  if 
well-marked,  it  should  no  more  be  stigmatized  as 
"pseudo,"  because  it  occurs  in  youth,  than  the 
lesion  with  which  it  is  sometimes  associated  should 
be  called  functional  because  it  ha^Dpens  to  be 
curable.  At  the  same  time  there  are  plenty  of 
„  pains  to  be  found  about  the  left  side 

Many  precor-     ^ 

diaipains  not  of  the  chest,  and  even  in  connection 
anginous.  ^-^j^  ^-^q  heart  itself,  which  are  not 
angina,  and  these  it  is  of  importance  to  differenti- 
ate for  the  patient's  comfort  as  well  as  for  his 
treatment. 

1  Oj).  cit.,  May,  1880,  p.  146.         2  Balfour,  ojx  cit.,  p.  300. 


ANGINA   PECTORIS  117 

Constipation  dependent  on  torpor  of  the  colon, 
especially  if  associated  with  chlorosis,  is  not  infre- 
quently accompanied  with  neuralgic  pains  radiat- 
ing from  the  neighbourhood  of  the  scrohiculus 
cordis  over  the  edge  of  the  false  ribs,  and  some- 
times shooting  into  the  cardiac  area  itself.  The 
pain  in  such  a  case  is  constant  with  occasional 
exacerbations ;  it  always  radiates  from  some  part 
of  the  colon,  and  may  shoot  round  the  chest,  or 
even  into  the  cardiac  area,  but  never  upwards  or 
into  either  arm ;  it  is  not  increased  by  exercise, 
nor  does  it  get  worse  during  night.  The  heart 
may  have  all  the  usual  chlorotic  murmurs,  but 
the  pulse  is  always  soft  and  compressible.  This 
neuralgia  is   curable,  but  not  always  readily  so. 

Torpor  and  congestion  of  the  liver,  so  constant 
an  accompaniment  of  gastro-duodenal  dyspepsia, 
is  often  associated  with  pain  below  either  clavicle, 
about  the  second  interspace.  This  probably  arises 
from  irritation  of  the  phrenic  nerve  shooting  as 
pain  into  the  upper  intercostal  nerves.  On  the 
right  side  this  simulates  lung  disease ;  on  the  left 
side  it  is  apt  to  be  mistaken  for  a  heart  pain. 

Intercostal  myalgia  and  neuralgia  often  encroach 
upon  the  cardiac  area  and  get  referred  to  the 
heart;  also  acute  commencing  pleurisy,  often  free 
from  friction  because  movement  is  so  painful,  if 
near  the   cardiac   area,  gets   talked  of  as  a  heart 


118  THE   SENILE   HEART 

pain,  though  here  the  thermometer  helps  to  keep 
the  diagnosis  right.  The  heart  itself  often  suffers 
from  burning,  stinging,  or  cutting  pains,  the  exact 
nature  of  which  it  is  not  always  easy  to  determine, 
but  which  probably  are  always  either  of  a  rheu- 
matic or  gouty  character  —  most  probably  gouty. 
Finally,  there  is  a  cardiac  pain  dependent  upon 
pressure  on  the  cardiac  nerves.  If  the  tumour, 
whatever  its  character,  which  produces  this  press- 
ure and  pain  is  too  small  to  be  detectable,  and 
especially  if  it  occurs  in  youth  or  early  middle 
life,  the  pain  itself  is  apt  to  be  stigmatized  as 
a  spurious  angina,  as  a  mere  neurotic  pain  to  be 
fought  against.  And  yet  the  ailment  may  be  serious 
enough  to  cause  sudden  death  erelong,  and  of  this 
I  have  seen  several  instances.  It  is  easy  enough 
to  separate  a  pain  of  this  kind  from  true  angina, 
if  we  get  the  chance  of  seeing  a  paroxysm,  but 
then  the  difficulty  begins.  In  true  angina  the 
danger  is  great,  and  the  prognosis  always  serious, 
because  true  angina  depends  upon  an  interference 
with  the  function  of  the  katabolic  nerve,  and  in 
its  mildest  form  instantly  threatens  the  citadel  of 
life.  But  in  what  we  may  term  —  for  want  of  a 
better  expression  —  false  angina,  we  have  only  to 
deal  with  pain,  the  danger  of  which  depends  upon 
its  cause ;  if  the  pain  is  caused  by  the  pressure  of 
a  gland,  the  danger  may  be  but  slight;  but  if  it  be 


ANGINA   PECTORIS  119 

caused  by  a  small  substernal  aneurism,  the  danger 
is  great  and  imminent.  In  a  few  such  cases  it  is 
possible  to  make  a  fairly  accurate  diagnosis ;  in 
others,  this  is  absolutely  impossible.  There  is  no 
class  of  cases  in  which  greater  care  and  circum- 
spection are  required,  and  even  with  the  largest 
experience  an  error  may  be  committed;  for  the 
patient's  sake  it  is  better  to  err  in  excess  of  cau- 
tion. Various  authors  —  amongst  them,  Anstie  ^ 
and  Huchard^  —  have  laid  down  certain  rules  for 
simplifying  the  diagnosis  between  true  and  false 
angina,  Huchard  especially  has  entered  very  fully 
into  the  question ;  but  there  is  not  one  of  the 
many  indications  commented  upon  which  is  not 
liable  to  serious  exception,  and  with  the  greatest 
care  doubtful  cases  will  always  occur  in  which  a 
perfectly  accurate  diagnosis  seems  impossible.  In 
saying  this  I  refer  specially  to  one  case  well 
known  to  myself  as  well  as  to  others.  In  the  case 
referred  to  there  is  no  suspicion  of  hysterical 
exaggeration  of  any  of  the  ordinary  neuralgise, 
described  as  occasionally  implicating  the  region 
of  the  heart.  This  patient  was  formerly  a  nurse 
in  one  of  the  largest  hospitals  in  Britain,  and  has 

1  Neuralgia  and  its  Counterfeits,  London,  Macmillan  &  Co., 
1871,  p.  75. 

2  Maladies  du  Coeur  et  des  Vaisseaux,  Paris,  1893,  2me  eel., 
p.  719.     Huchard  has  gone  very  fully  into  the  whole  subject. 


120  THE   SENILE  HEART 

been  seen  in  her  attacks  by  some  of  the  ablest 
physicians,  who  have  always  treated  her  as  suffer- 
ing from  true  angina.  She  has  long  been  happily 
married,  though  without  family,  and  marriage  has 
neither  increased  nor  diminished  the  frequency 
or  intensity  of  her  attacks.  During  the  last 
twelve  years  I  have  repeatedly  seen 
C'ase  of  doubt-  ^^^^  examined  her,  and  I  have  always 

Jul  angina. 

doubted  the  reality  of  her  seizures. 
She  has  pain,  no  doubt,  but,  though  a  woman  over 
fifty,  she  is  too  healthy  and  blooming  to  suffer 
from  true  angina.  I  have,  however,  never  had  an 
opportunity  of  seeing  one  of  her  attacks.  Only 
to-day  —  as  I  was  writing  this  —  she  called  and 
told  me  that  of  late  she  had  been  suffering  from 
gouty  pains  in  her  joints,  especially  in  her  fingers 
and  wrists ;  and  she  added,  "  While  I  have  these 
pains  I  am  so  irritable  that  I  am  a  nuisance 
to  myself  and  to  every  one  about  me ;  and  what 
puzzles  my  doctor  as  well  as  myself  is  that 
while  I  have  these  pains  I  have  none  of  my 
old  attacks,  but  the  moment  the  pains  leave  my 
joints  I  get  one  of  my  old  attacks."  Obviously 
this  is  —  after  all  these  years  —  the  clue  to  her 
case ;  evidently  she  has  a  recurrent  gouty  neu- 
ralgia of  the  heart,  an  angina,  no  doubt,  of  a 
kind,  yet  neither  a  true  nor,  properly  speaking,  a 
pseudo-angina. 


ANGINA   PECTORIS  121 

As  a  rule  it  is  not  difficult  to  differentiate  all 
the  varieties  of  cardiac  pain  from  angina  as  well 
as  from  one  another,  though,  in  a  doubtful  case, 
the  observation  of  an  attack  —  when  that  is  pos- 
sil3le  —  may  be  of  the  greatest  assistance. 

We  must  not  forget  that  in  the  syndrome  of 
angina  pain  —  even  though  severe  —  plays  but  a 
subordinate  part,  while  in  all  those  other  affec- 
tions which  simulate  it  pain  is  the  prominent  and 
paramount  symptom. 

In  a  severe  attack  of  angina,  the  patient  dare 
scarcely  breathe  till  the  pain  abates,  not  because 
of  the  pain,  but  by  reason  of  that  awful  sense  of 
impending  dissolution  of  which  the  pain  is,  as  it 
were,  the  subjective  symbol.  But  all  attacks  are 
not  so  severe,  and  a  certain  amount  of  jactitation 
is  sometimes  observed,  while  in  the  angina  associ- 
ated with  aortic  regurgitation,  forced  inspiration 
and  violent  movements  of  the  arms  are  occasion- 
ally resorted  to  with  the  object  of  relieving  the 
agonizing  pain,  and  sometimes  successfully.^ 

As  some  of  the  acknowledged  causes  of  angina 

may  be  present  in  the  young  as  well  as  in  the  old, 

we  are  justified  in  regarding-  as   true 

Case  of  true  ^  . 

angina  in  a      angina    any    paroxysmally    recurrnig 
young  woman  QQ^^dmc  pain  which  cannot  be  referred 

of  tiventy-Jive.  .      . 

to  any  of   the  varieties    of   neuralgia 
1  Vide  Balfour,  op.  cit.  second  edition,  1882,  pp.  273  and  306.' 


122  THE   SENILE  HEART 

just  described,  even  although  it  occurs  in  a  young 
person,  and  may  be  associated  with  more  or  less 
jactitation.  Of  this  there  could  scarcely  be  a  better 
example  than  the  following  case :  In  September 
1888,  a  young  married  woman  was  sent  for  my 
opinion,  with  the  following  history :  "  M.  S.,  set. 
25 ;  married  five  years  ago ;  has  had  two  children, 
the  last  of  them  a  month  ago ;  has  hereditary  pre- 
disposition to  angina.  About  eight  years  ago  she 
had  diphtheria  with  pericarditis,  from  which  she 
made  a  good  recovery  under  the  care  of  the  late 
Dr.  Kelburne  King.  She  was  married  five  years 
ago,  became  pregnant,  and  during  the  first  six 
months  she  suffered  much  from  attacks  of  syn- 
cope. She  made  a  fair  recovery  from  childbirth. 
During  the  last  three  and  a  half  years  she  has 
suffered  increasingly  from  syncopal  attacks,  pre- 
ceded by  or  accompanied  with  pains  of  an  anginal 
character.  She  derives  considerable  benefit  from 
nitrite  of  amyl  inhalations,  which  cut  the  attack 
short.  She  was  confined  of  her  second  child  about 
a  month  ago,  and  recovered  strength  very  slowly, 
until  digitaline  was  administered,  when  she  im- 
proved rapidly."  I  found  Mrs.  S.'s  heart  well 
contracted  and  slightly  thumping  in  its  action 
from  three  of  Nativelle's  granules  having  been 
taken  daily  for  some  time.  She  stated  that  her 
anginal  attacks  were   always   preceded  by  pallor 


ANGINA   PECTORIS  123 

of  the  face  and  fingers,  that  she  could  move 
about  freely  during  the  attack,  and  that  it  was 
always  relieved  by  stimulants  or  by  nitrite  of 
amyl  inhalations.  The  symptoms  and  history  of 
this  case  showed  it  to  be  one  in  which  the  attacks 
were  probably  due  to  arterial  spasm  raising  the 
blood  pressure,  and  thus  throwing  an  undue  strain 
upon  a  feeble  spansemic  heart  which  had  been 
somewhat  dilated;  the  nervous  phenomena  being 
obviously  due  to  the  instability  of  the  nervous 
system,  an  instability  the  result  of  imperfect  nutri- 
tion. Evidently  a  case  liable  to  be  branded  as  a 
hysterical  or  pseudo-angina,  but  really  a  case  of 
true  angina  occurring  in  a  young  neurotic  female, 
from  a  curable  cause,  and  with,  therefore,  a  favour- 
able prognosis.  Two  years  subsequently  T  enquired 
as  to  her  progress,  and  received  the  following  reply : 
"  I  may  report  favourably  as  to  Mrs.  S.  The  an- 
ginous  character  of  her  attacks  gradually  became 
less  marked,  and  her  general  health  much  improved. 
She  has  since  had  another  baby,  making  a  good 
recovery." 

I  have  called  this  a  case  of  true  angina,  and 
such  it  undoubtedly  was,  meaning  by  angina  a  pain 
of  the  heart  induced  by  a  call  for  increased  exer- 
tion, as  in  this  case  from  a  reflex  rise  of  blood 
pressure,  as  in  others  from  mere  bodily  exertion. 

With  this  conception  of  angina,  we  can  under- 


124  THE   SENILE  HEART 

stand  that  it  may  vary  much  in  degree.  Probably 
the  slightest  possible  form  of  it  is  the  sharp  pain 
p  .     .  that  occasionally  accompanies  the  aug- 

angina  may  mentor  action  following  an  intermis- 
vary  muc  i.  gjon,  or  a  short  spell  of  tremor  cordis 
in  a  spansemic  heart. 

Apart  from  the  trifling  form  just  referred  to, 
the  pain  of  angina  varies  from  a  dull  agonizing 
ache,  to  a  feeling  as  if  a  mailed  hand  grasped  the 
chest  in  the  cardiac  area  and  squirted  through  its 
fingers  flashes  of  excruciating  agony  up  to  the  left 
shoulder  joint,  sometimes  into  both  shoulder  joints, 
extending  down  to  the  elbow  or  along  the  ulnar 
nerve  to  the  fourth  and  third  fingers  on  the  left  or 
on  both  sides.  Occasionally  the  pain  shoots  up  the 
neck,  generally  on  the  left  side  ;  or  into  the  scrohi- 
culus  cordis  ;  more  rarely  it  shoots  down  the  loins 
and  legs.  The  sufferer  has  a  feeling  of  choking, 
but  the  breathing  is  perfectly  free,  and  is  only 
restrained  by  the  dread  lest  the  slightest  movement 
should  precipitate  the  end  which  seems  so  terribly 
near.  The  countenance  may  be  pinched,  ghastly 
pale,  and  covered  with  beads  of  perspiration  (^facies 
Hippocraticd).  But  often  the  face  is  quite  un- 
changed, save  only  for  an  anxious,  haggard  expres- 
sion. In  the  angina  that  occasionally  complicates 
aortic  regurgitation  or  indicates  substernal  aneu- 
rism, as  well  as  in  that  associated  Avith  other  more 


■ANGINA   PECTORIS  125 

curable  cardiac  affections,  the  pain  is  more  acute, 
less  oppressive  and  appalling,  and  it  is  sometimes 
conjoined  with  so  much  jactitation  as  to  simulate 
a  pure  neurosis. 

The  causes  of  angina  may  seem  to  be  various, 
but  they  are  all  of  a  kind  to  depress  the  djmamic 
force  of  the  nerve  implicated,  or  of  the 

.  The  cause  of 

heart   itself,    which  is   the   automatic  angina 
source  of  its  own  energy.    Pressure  on  «^^^«?/s  s^^^e 

(2Bt)Tsssctyit  of 

some  of  the  nerves  of  the  cardiac  or  nervous  or 
aortic  plexus  is  not  an  infrequent  cause  <^'^'>^^^^(^^- 

energy. 

of  angina.  This  pressure  may  be  pro- 
duced by  a  tumour,  often  a  very  small  one ;  by  a 
small  substernal  aneurism,  which  usually  escapes 
detection ;  or  by  a  dilated  aorta,  sometimes  without, 
but  more  commonly  associated  with,  regurgitation 
through  the  semi-lunar  valves. 

One  of  the  most  common  concomitants  of  angina 
is  sclerosis  of  the  coronary  arteries  ;  indeed,  so 
common  is  the  conjunction  that  the  arterial  scle- 
rosis has  often  been  looked  upon  as  the  cause  of 
the  angina.  But  coronary  sclerosis  is  too  often 
present,  where  there  never  has  been  any  angina, 
to  permit  the  concurrence  being  looked  upon  as 
anything  more  than  accidental.  Fatty  degenera- 
tion of  the  myocardium  is  often  found  where 
angina  has  been  present  during  life,  and  it  too 
has  been  supposed  to  be  a  cause  of  the  angina ; 


126  THE   SENILE  HEART 

but,  like  arterial  sclerosis,  fatty  degeneration  of 
the  myocardium  is  very  often  found  where  there 
has  been  no  antecedent  angina.  Like  coronary 
sclerosis  itself,  therefore,  fatty  degeneration  of  the 
myocardium  can  only  be  regarded  as  a  concomi- 
tant of  angina,  and  not  as  a  cause.  On  the  other 
hand,  fatty  degeneration  of  the  myocardium  is  due 
to  faulty  metabolism  from  an  imperfect  blood-sup- 
ply to  the  part  affected ;  an  imperfect  blood-supply 
is  a  common  result  of  arterial  sclerosis,  and  is  in 
fact  the  connecting  link  between  coronary  scle- 
rosis and  fatty  myocardium.  It  is  the  one  common 
factor  these  two  conditions  have  —  of 
Angina  ^^  ^^^  ^^  ^^  ^  result,  and  of  the  other 

almost  mva- 

riabhj  the         a  causc.     And  when  we  inquire  into 

result  of  car-  ^^^  matter,  wc  find  that  an  imperfect 
diacischsemia.  '  ^ 

blood-supply  is  a  factor  common,  not 

only  to  the  conditions  just  referred  to,  but  also  to 
almost  every  condition  of  heart  with  which  angina 
has  ever  been  found  associated.  Among  these  we 
may  reckon  embolism  and  thrombosis  of  the  cor- 
onary arteries  —  diminution  of  the  calibre  of  these 
vessels  at  their  origin  at  the  root  of  the  aorta,  or 
in  their  course  through  the  heart,  by  inflammatory, 
atheromatous,  or  syphilitic  processes.  On  rare 
occasions  the  heart  in  late  life  becomes  enlarged 
beyond  the  feeding  powers  of  coronary  arteries  con- 
genitally  deficient  in  size  or  in  number,  as  happened 


ANGINA   PECTORIS  127 

in  the  case  of  Dr.  Arnold.^  More  commonly,  simple 
dilatation  and  hypertrophy  get  in  excess  of  the  feed- 
ing powers  of  the  ordinary  coronaries,  because  of 
some  failure  in  the  quality  of  the  nutriment  supplied. 
A  good  deal  has  been  said  about  tobacco  and 
tea  as  causes  of  angina,  especially  by 
French  writers,  as  if  the  nicotine  and   Tobacco,  tea, 

and  gastric 

theine  produced  it  oi  themselves  by  a  derangements 

special  act  of  poisoning.      But  angina    Produce  an- 
gina only  by 

from  these  causes,  as  well  as  from  gas-  enfeebling  the 
trie  derangements,  is  a  rare  accident,  heart,  and  m- 

ducing  rela- 

and  never  happens   unless   there   has   uve  ischsemia. 
been    some    previous    spangemia,    and 
some  slight  dilatation  of   the   heart.      It  accom- 
panies, or  rather  follows,  some  preceding  irregu- 
larity of  the  heart's  action  ;  this  we  know  involves 

1  The  size  of  the  coronaries  is  quite  disproportionate  to  the 
mass  of  muscle  to  be  fed,  so  that  the  heart  may  be  looked  on  as 
having  an  excessive  supply  of  blood  compared  with  other  mus- 
cles.—  Odriozola,  Etude  siir  le  Cosur  senile,  Paris,  1888,  p.  5. 
Dr.  Arnold  died  at  forty-seven  of  his  first  attack.  "  The  heart 
was  rather  large.  .  .  .  The  muscular  structure  of  the  heart 
was  in  every  part  remarkably  thin,  soft,  and  loose  in  its  texture. 
The  walls  of  the  right  ventricle  were  specially  thin,  in  some 
parts  not  much  thicker  than  the  aorta.  ...  Its  cavity  was 
large.  The  walls  of  the  left  ventricle,  too,  were  much  thinner 
and  softer  than  natural,  and  the  muscular  fibres  of  the  heart 
generally  were  pale  and  brown.  .  .  .  There  was  but  one  cor- 
onary artery,  and,  considering  the  size  of  the  heart,  it  appeared 
to  be  of  small  dimensions." — Latham,  Diseases  of  the  Heart. 
London,  1846,  Vol.  ii.,  p.  377. 


128  THE   SENILE  HEART 

lessening  of  the  ventricular  output,  with  conse- 
quent residual  accumulation  and  ventricular  dila- 
tation (vide  antea^  p.  41).  To  empty  the  ventricle 
in  this  condition  the  augmentor  nerve  is  called 
into  play,  and  this  call  for  extra  exertion  is  the 
incitation  to  angina.  Not  because  tobacco  and  tea 
are  poisons  specially  incentive  to  angina,  but  be- 
cause their  abuse  has  so  lowered  the  health  and 
impoverished  the  blood  as  to  enfeeble  the  myocar- 
dium and  induce  a  relative  ischsemia,  an  ischaemia 
of  quality  though  not  of  quantity.  Spansemic 
blood  involves  imperfect  nutrition,  and  as  the 
energy  of  the  heart  depends  upon  the  perfection 
of  its  metabolism,  long  continuance  of  imperfect 
nutrition  implies  a  commensurate  loss  of  cardiac 
energy.^  After  middle  life  this  is  always  a  serious 
matter,  and  even  in  youth  it  is  not  devoid  of  dan- 
ger, and  may  precipitate  a  fatal  issue. 

The  vigour  of  a  muscle  may  vary  from  nothing 

to  a  maximum,  and  depends  upon  the 
imperfect  perfection  of  its  metabolism.  An  or- 
cardiac  dinary  skeletal  muscle  only  possesses 

irritability  towards  stimuli ;  but  the 
heart  has  not  only  the  power  of  originating  spon- 
taneous rhythmic  movements,  but  is  also  able  to 

1  Von  Bezold,  Untersuchnngen  aus  dem  physiologischen  La- 
boratorutni  in  Wurzburg,  Leipzig,  1867  j  Erster  Theil,  S. 
279,  etc. 


ANGINA   PECTORIS  129 

store  a  reserve  of  energy  so  great  that,  in  some 
animals,  these  spontaneous  movements  go  on  for 
hours  after  the  heart  has  been  separated  from  the 
body.  It  is  evident,  therefore,  that  the  metabolism 
of  the  heart  is  of  a  very  much  higher  order  than 
that  of  the  skeletal  muscles,  and  is  all  the  more 
readily  affected  injuriously  by  any  changes  in  the 
quantity  or  quality  of  the  blood  which  furnishes 
its  basis.^  The  large  reserve  of  energy  with  which 
the  heart  starts  on  its  extra-uterine  life,  and  which 
is  always  maintained  during  healthy  life,  enables 
it  at  any  age  long  to  resist  hurtful  influences  of 
this  character,  but  in  time  they  tell. 

When  a  bad  bout  of  irregularity  or  intermission, 
induced  by  mental  emotion  or  any  other  cause,  or 
when  such  an  increase  of  muscular  exertion  as  is 
involved  in  going  up  a  stair,  or  any  acclivity,  or 
when  any  sudden  rise  of  blood  pressure,  from 
reflex  causes,  calls  for  increased  action 
in  a  heart  with  its  energ^y  impaired   ^«^«eo/ayf« 

^"^  ^  of  angina. 

by  malnutrition  from  long-continued 
spansemia,  by  positive  obstruction  to  the  coronary 
circulation,  or,  as  is  more  frequently  the  case,  by 
a  combination  of  both,  the  response  may  be  so 
imperfect  that  the  function  of  the  augmentor 
nerve  is  sensibly  impeded.  The  call  for  increased 
katabolic  action  is  at  once  followed  by  sudden 
1  Foster,  op.  cit.,  p.  344. 


130  THE  SENILE  HEART 

exhaustion,  and  this  is  revealed  as  an  agonizing 
pain  beneath  the  sternum,  that  shoots  along  some 
or  all  of  those  sensitive  spinal  nerves  with  which 
the  sympathetic  or  katabolic  nerve  is  embryologi- 
cally  connected.^ 

Like  other  neuralgise,  angina  originates  in  a 
lowering  of  the  function  of  the  nerve  affected. 
Usually  the  nerve  function  is  lowered  by 
long-continued  imperfect  nutrition,  occasionally 
brought  to  a  climax  by  some  positive  cause  of 
ischsemia,  as  vascular  spasm,  etc.  More  rarely 
the   nerve    function   is    depressed    by 

XscIicBt)xzci  zs 

well  known  to  actual  pressure  upon  some  of  the 
be  a  cause  of     branches  of  the  cardiac  or  aortic  plex- 

severe  j^ain. 

uses,  by  an  aneurism,  a  tumour,  or  a 
dilated  aorta.  Those  conditions  which  do  not 
necessarily  involve  ischgemia  have  always,  in  my 
experience,  been  accompanied  by  a  less  severe, 
though  not  always  a  less  dangerous,  form  of 
angina. 

I  suppose  Jenner  was  the  first  to  point  out  the 
probable  connection  between  ischsemia  and  angina. 
He  does  not  explicitly  state  this  connection,  but 
he  certainly  implies  it  in  saying,  "  The  importance 
of  the  coronary  arteries,  and  how  much  the  heart 
must  suffer  from  tlieir  not  being  able  to  fulfil  their 

1  Vide  Gaskell,  The  Journal  of  Physiology,  Yo\.  vii.,  p.  1, 
and  especially,  pp.  41  and  4G. 


ANGINA   PECTORIS  131 

function,  I  need  not  enlarge  upon."  ^  As  Kreysig 
has  said,  "  The  loord  ischsemia  was  not  then  in- 
vented, but  the  tiling  itself  was  well  known."  ^ 
That  ischsemia  does  give  rise  to  pain,  even  of  the 
most  atrocious  character,  is  sufQciently  attested 
by  the  agony  that  attends  compression  of  an  artery 
for  aneurism,  especially  at  the  moment  the  vessel 
becomes  completely  occluded;  the  pains,  arising 
from  a  similar  cause,  that  precede  the  appearance 
of  gangrenous  patches  in  a  limb  affected  with 
senile  gangrene  ;  and  those  which  precede,  accom- 
pany, and  follow  attacks  of  local  asphyxia  (Ray- 
naud's disease).  There  is  every  reason  to  suppose 
that  the  arterial  spasm,  which  is  so  evidently  the 
cause  of  local  asphyxia,  and  which  takes  so  promi- 
nent a  share  in  the  production  of  an  attack  of 
angina  vaso-motoria^  occasionally  invades  the  heart 
either  as  part  of  a  general  condition,  or  it  may  be 
as  a  distinctly  local  affection,  and  that  this  is  a 
very  possible  cause  of  those  anginal  attacks  where 
no  other  seems  obvious.     For  myself   ^, 

"^  The  most  seri- 

I  can,  however,  say  that  I  have  never  ous  forms  of 
yet  seen  a  case  of  true  cardiac  ang-ina  "/^^'^^f^  ^''^ . 

•^  ^  those  in  vmich 

in  which  I  have  been  unable  to  detect  the  least  is  to 
some  of  the  physical  signs  of  dilata-  ^'  '^'^''^'^' 

1  Letter  to  Heberden  in  1778.     Vide  Baron's  Life  of  Jenner, 
Vol.  i.,  p.  40. 

2  Krankheiten  des  Herzens,  Berlin,  18 10,  Bd.  ii.,  S.  544. 


132  THE   SENILE  HEART 

tion  of  the  heart.  It  may,  indeed,  be  accepted 
as  a  fact,  to  which  I  know  of  no  exceptions, 
that  the  less  there  seems  to  be  the  matter  with 
the  heart  the  more  grave  is  the  prognosis,  if  the 
anginous  attacks  are  at  all  serious. 

In  angina  pectoris,  as  in  other  neuralgise,  we 
have  the  presence  of  a  permanent  lesion  coupled 
with  only  occasional  attacks.  For  these  attacks 
there  is  always  some  more  or  less  obvious  cause. 
Parry  said  long  ago  that  the  symptoms  of  angina 
arise  from  a  temporary  increase  of  weakness  in  an 
organ  already  weakened.^  Doubtless  this  is  the 
case  when  spasm  affects  the  coronaries  and  dimin- 
ishes the  blood-supply  of  a  heart  already  suffering 
from  malnutrition.  As  a  rule,  however,  it  is  quite 
the  other  way ;  it  is  not  the  weakness  of  the 
heart,  but  the  work  it  has  to  do,  that  is  in- 
creased, and  the  work  may  be  increased  in  various 
ways. 

Exertion  is  the  commonest  cause  of  increased 

cardiac  action,  because  the  metabolism  of  the  heart 

and   other   muscles,    when   in   action. 
Various  ways  n      i 

in  which  ail-     requires  more  frequent  flushing  with 

gma  mmj  be  Ijlood  than  when  they  are  quiescent, 
brought  about.  ^  ^       ^    '       i    c       • 

especially  if  the  blood  is  defective  m 
oxygen    or  in   nutritive   material.     And  exertion 
after  a  meal  is   more   apt  to  induce  a  paroxysm 
i  Quoted  by  Stokes,  op.  cit.,  p.  486. 


ANGINA    PECTORIS  133 

than  when  the  stomach  is  empty ;  first,  because 

a  full  stomach  impedes  and  oppresses 

the  heart ;  and  second,  because  shortly  ^^^^^^J^^^^ 

after   a    meal    the    vessels    are    fuller 

and  the  blood  pressure  somewhat  raised. 

Any  overwhelming  emotion  may  prove  suddenly 
fatal  by  its  action  on  the  heart,  and  when  sudden 
death  has  been  preceded  by  repeated 
attacks  of  angina,  as  in  the  case  of  ^^^^^^^^^ '^^''^ 
John  Hunter,  it  has  been  assumed  that 
death  has  been  due  to  this  cause.  And  this  as- 
sumption is  probably  correct  though  the  fatal 
seizure  is  often  an  angina  sine  dolore,  an  instanta- 
neous death  without  a  cry  or  any  indication  of 
suffering.  In  such  cases  the  heart  may  be  sud- 
denly arrested  in  diastole  through  vagus  action, 
an  arrest  which  the  katabolic  action  of  the  aug- 
mentor  nerve  fails  to  overcome;  or  the  emotion 
may  induce  irregularity  with  residual  accumula- 
tion, which  the  augmentor  nerve  fails  to  expel. 
In  the  one  case  death  is  instantaneous,  as  in  so 
many  recorded  instances  (vide  note,  p.  31,  antea)  ; 
in  the  other  case,  as  in  that  of  John  Hunter,  there 
may  be  time  to  retire  to  an  adjoining  apartment 
before  the  heart  actually  fails  and  death  ensues. 
In  both  forms  death  arises  from  failure  of  kata- 
bolic action,  and  both  may,  therefore,  be  claimed 
as  deaths  from  angina. 


134  THE  SENILE  HEART 

Exposure  to  cold,  especially  to  a  cold  wind  strik- 
ing the  chest,  is  a  very  common  cause  of  angina ; 

the  attacks  thus  brought  on  are,  how- 
g^^^      ■  ever,  oiten  so  slight  as   almost  to   be 

regarded  as  mere  neuralgia  —  nerve 
pain  —  from  cold,  were  it  not  that  relief  so  immedi- 
ately follows  the  use  of  nitro-glycerine  —  or  some 
similar  remedy  —  as  to  make  it  clear  that  the  chill- 
ing of  the  surface  had  sufficed  to  contract  the  super- 
ficial vessels,  and  so  raised  the  blood  pressure  as 
to  induce  a  paroxysm  of  angina. 

Occasionally  the  spasm  of  the  vessels  arises  not 
from  cold,  but  from  some   internal  cause ;   some 

organic  derangement  —  stomach,  liver, 

Vaso-motor       ^^  other  orP^an  ;  or  from  some  impurity 
angina.  ^  j.  ./ 

of  the  blood ;  and  then  we  have  cold- 
ness and  numbness  of  one  or  more  of  the  extremi- 
ties, followed  immediately  by  anginous  pain.^  In 
one  such  patient  the  coldness  and  numbness  at 
first  affected  the  right  arm  alone,  and  his  heart  was 
fairly  good,  but  this  organ  dilated  considerably 
before  his  death,  which  happened  suddenly  about 
two  years  after  he  was  first  seen. 

Pain,  though  so  usual  a  concomitant  of  an  attack 
that  angina  cannot  even  be  thought  of  without 

1  Landois,  Lehrhuch  der  Physwlof/ie  des  3fenschen,  7te  auf- 
lage,  Wien  u.  Leipzig,  1891,  p.  817.  Also  Eulenberg,  Ziems- 
sens  Cyclopedia,  Vol.  xiv.,  p.  48. 


ANGINA   PECTORIS  135 

bringing  up  with  it  the  idea  of  intense  agony,  yet 
forms  no  essential  part  of  the  disease,  and  it  is  no 
misnomer  to  speak  of  angina  sine  dolor e.^  Most  if 
not  all  fatal  cases  are  of  this  character ;  so  far  as 
my  experience  goes,  by  far  the  greater  number  of 
fatal  seizures  have  been  apparently  painless. 

In  ordinary  cases  of  painless  angina  there  is 
breathlessness,  but  no  pain,  and  the  attack  gets  the 
name  of  cardiac  asthma.^  A  nocturnal  attack  of 
cardiac  asthma  is  often  the  beginning  of  the  end,  the 
earliest  indication  that  the  senile  heart 
has  become  seriously  dilated.  Now  asthma  a 
and  then  ordinary  attacks  of  painful  vaso-motor 

T    .  1,1         1  c    angina  sine 

angina  cease,  and  towards  the  close  oi  (joiore. 
life  the  patient  suffers  only  from  fits  of 
breathlessness.  At  other  times  the  attacks  of  pain 
and  of  breathlessness  alternate.  And  at  still  other 
times  the  pain,  with  which  the  attack  commenced, 
passes  off  and  leaves  behind  it  a  cardiac  asthma  as  a 
continuance  of  the  seizure.  I  myself  have  assisted 
at  the  development  of  a  case  of  the  last  mentioned 

1  Vide  Gairdner  in  Reynold^s  System  of  Medicine,  Vol.  iv., 
p.  566. 

2  Stokes  says  :  "  Well-marked  instances  of  the  affection  as 
described  by  Latham  are  rarely  met  with,  and  the  same  may 
be  said  of  the  purely  nervous  cases  noticed  by  Lgennec.  I  have 
never  seen  either  of  these  forms.  The  disease  which  in  this 
country  (Ireland)  most  often  gets  the  name  of  angina  pectoris 
might  be  more  properly  designated  cardiac  asthma."  —  Op.  cit., 
p.  488, 


136  THE   SENILE  HEART 

variety.      A   man  aged    fifty-seven    had    suffered 

from  angina  occasionally  for  years ;  the 
Case  of  trans- 
ference of         seizure  was  brought  on  by  exertion  or 

pressure  from   j^y  emotioii,  and  the  pain  shot  from 

the  aortic  to 

thepuimo-        mid-sternum  through  to  the  back  and 
nary  vascular   (J^qwu  the  left  arm,  Occasionally  down 

system.  i  •  i  i 

the  left  leg,  and  sometimes  down  the 
right  arm  also.  The  heart  had  a  feeble  impulse 
and  was  slightly  irregular,  the  aortic  second  was 
accentuated,  and  the  first  sound  over  the  apex 
was  blunt.  The  radial  pulse  was  tense.  Signs 
which  indicated  a  high  blood  pressure  and  a  dilat- 
able and  probably  somewhat  dilated  heart.  While 
I  was  listening  to  his  heart  sounds,  nervous  excite- 
ment brought  on  an  attack  of  angina,  pain  accom- 
panied by  a  feeling  of  suffocation.  Gradually,  as  I 
listened,  a  distinct  auricular  murmur  developed, 
and  pai^i  passu  with  this  the  pulmonary  second 
became  not  only  markedly  accentuated,  but  also 
acquired  a  booming  quality.  Evidently  residual 
accumulation,  due  to  irregular  and  imperfect  ven- 
tricular contraction,  had  overdistended  the  ventricle 
and  promoted  regurgitation  through  the  mitral 
opening,  causing  considerable  pulmonary  conges- 
tion. From  the  same  cause  the  radial  pulse,  which 
had  been  firm  and  tense,  became  gradually  small 
and  feeble.  Obviously  there  had  been  a  transfer- 
ence of  the  blood  pressure  from  the  aortic  to  the 


ANGINA   PECTORIS  137 

pulmonary  system,  and  with  that  an  increase  of 
the  breathlessness,  amounting  to  a  slight  attack 
of  cardiac  asthma. 

No  doubt  ordinary  attacks  of  cardiac  asthma  of 
the  kind  I  now  speak  of  have  all  a  similar  origin ; 
irregular  or  imperfect  cardiac  action,  not  marked 
enough  to  induce  anginous  pain,  yet  avails  to 
induce  residual  accumulation  and  mitral  regurgi- 
tation in  a  dilated  or  dilatable  heart,  and  so  an 
attack  that  begins  as  a  reflex  spasm  of  the  systemic 
arterioles  ends  in  pulmonary  congestion  and  cardiac 
asthma. 

In  one  old  lady  the  illness  commenced  with  an 
attack  of  pain  in  the  scrohiculus  cordis  simulating 
the  passage  of  a  gallstone  ;  ^  her  subsequent  attacks 
were  simply  fits  of  intense  breathlessness  without 
pain,  accompanied  by  a  feeble,  wobbling  heart-beat, 
and  a  hard,  wiry  pulse  of  high  tension.  As  this 
tension  relaxed  and  the  pulse  became  soft,  the  attack 
passed  away.  After  a  very  severe  attack  one  even- 
ing, which  lasted  over  an  hour,  she  fell  asleep, 
woke   in  the  early  morning  with  a  slight  attack 

1  "  It  occasionally  happens  that  the  very  intense  and  sickening 
pain  of  biliary  calculus  presents  a  degree  of  resemblance  to 
angina  in  its  accessories ;  and  the  author  has  even  observed 
cases  in  which  the  diagnosis  remained  doubtful  until  the  yellow 
tinge  of  the  conjunctiva,  appearing  after  an  interval  of  hours, 
relieved  the  apprehensions  of  the  physician. "  —  Gairdner,  loc. 
cit.,  p.  646. 


138  THE   SENILE   HEART 

of  Cheyne-Stokes  respiration,  and  passed  quietly 
away. 

Many  of  the  victims  of  fatal  angina  pass  away 

unobserved  during  the  night ;  but  not  a  few  have 

had  Ishmael's  privilege  of  dying  in  the  presence 

of  their  brethren,  sometimes  suddenly 

Death  from  ,        .  ,        ^  .  ,  .,         ^       ,i 

angina  uener-   ^^^^  Without  warning,  wliiie   at  other 
ally  painless,    times  death  has  been  preceded  by  a 

The  fatal  ,  .     ,       p  , 

asystole  may     i-ongQv  or  shorter  period  01  conscious 

be  sudden  or     sinking.^      So  far  as  my  own  experi- 
ingravescent.  i        n         i       ^  -i 

ence  goes,  by  lar  the  larger  number 
of  fatal  seizures  have  been  apparently  painless. 
Death  has  occurred  in  those  fatal  cases  precisely 
as  it  does  in  animals  which  have  had  their  coro- 
nary arteries  artificially  blocked ;  ^  sometimes  the 
heart  has  failed  suddenly  ;  at  other  times  complete 

1  In  one  recorded  case  this  conscious  sinking  occupied  quite 
half  an  hour.      Vide  Balfour,  oj7.  cit.,  p.  305. 

2  Vide  Panum,  Virchow's  Archiv,  Bd.  xxv.,  1862,  S.  308, 
etc. ;  Von  Bezold,  Untersuchungen  aus  dem  physiologischen 
Laboratorium  in  Wiirzburg,  erster  Theil,  1867,  S.  256,  etc.  ; 
and  See,  Comjites  Eendus,  Tome  xcii.,  1881,  p.  88.  See  found 
that  section  of  the  vagus  did  not  in  any  way  modify  the  phe- 
nomena produced  by  occlusion  of  the  coronaries,  and  also  that 
stimulation  of  the  vagus  had  no  effect  whatever  on  an  ischsemic 
heart.  Complete  ischsemia  is  not  always  immediately  fatal, 
because  of  the  enormous  reserve  of  energy  that  the  heart  pos- 
sesses, which  it  takes  some  time  to  exhaust.  But  a  long  con- 
tinuance of  imperfect  nutrition  modifies  this  reserve  of  energy 
in  a  most  important  manner,  diminishing  it  remarkably.  —  Von 
Bezold,  loc.  ciL,  S.  279. 


ANGINA   PECTORIS  139 

failure  has  been  preceded  by  a  longer  or  shorter 
period  of  ingravescent  asystole  (more  or  less  con- 
scious sinking), —  the  longer  or  shorter  time  occu- 
pied in  dying  evidently  depending  upon,  first,  the 
degree  of  ischsemia,  actual  or  relative,  present  in 
each  case,  and,  second,  the  length  of  time  during 
which  comparative  ischsemia  has  already  persisted, 
and  the  consequent  amount  of  exhaustion  which 
the  cardiac  energy  has  already  sustained.  The 
pre-existing  nutritional  vigour  of  the  heart,  and 
the  nature  of  the  exciting  cause,  have  all  some- 
what to  say  in  regard  to  the  actual  mode  of  death. 
One  gentleman,  over  eighty  years  of  age,  who  had 
long  suffered  from  angina,  took  his  seat  at  a  public 
meeting,  and,  without  a  sigh,  sank  down  dead.  I 
have  just  mentioned  (p.  138)  one  case  in  which 
ingravescent  asystole  occupied  fully  half  an  hour. 
When  I  entered  this  patient's  bedroom,  he  said 
to  me,  "  Doctor,  this  is  very  different  from  any- 
thing I  have  had  before,"  and  he  died  quietly, 
after  drinking  about  half  a  glass  of  brandy  given 
him  in  the  hope  of  stimulating  his  heart  to  more 
vigorous  contraction.  A  few  years  ago  I  saw  an 
old  gentleman  for  severe  angina.  Some  weeks 
subsequently  he  assisted  home  a  friend  who  had 
met  with  a  slight  accident ;  this  made  him  feel 
very  unwell,  but  he  struggled  to  reach  his  own 
home,  took  to  bed,  and  died  within  twelve  hours, 


140  THE   SENILE  HEART 

never  having  recovered  from  his  exhaustion.  An- 
other old  gentleman,  long  a  sufferer  from  angina, 
but  who  for  the  last  two  years  of  his  life  had  been 
free  from  pain,  a  week  before  he  died  had  what  was 
called  a  faint,  really  an  attack  of  cardiac  failure,  — 
an  angina  sine  dolore.  During  the  week  for  which 
his  life  was  spun  out  by  the  judicious  use  of  stim- 
ulants and  a  careful  avoidance  of  the  most  trifling 
exertion,  he  had  several  trifling  attacks  of  a  simi- 
lar character.  The  flnal  seizure  was  absolutely 
painless ;  life  ceased  because  the  heart  failed  to 
contract. 

Again,  during  last  winter  (1892-93)  there  was 
a  man  in  Chalmers  Hospital  suffering  from  aortic 
regurgitation,  accompanied  with  attacks  of  angina, 
with  a  tense  pulse  and  high  blood  pressure,  evi- 
dently of  reflex  origin  and  chiefly  occurring  at 
night.  After  much  suffering,  this  man's  strength 
at  last  broke  down ;  but  he  took  many  weeks  to 
die,  and  his  death  was  a  most  notable  example  of 
ingravescent  asystole  (vide  antea^  p.  80).  The 
degree  in  which  the  cardiac  energy  has  been  pre- 
viously exhausted  by  malnutrition  —  imperfect 
metabolism  —  regulates  the  rate  at  which  asystole 
progresses.  Long -continued  malnutrition  of  a 
serious  kind,  rapid  failure  at  the  last;  less  serious 
interference  witli  the  metabolism  of  the  heart,  in- 
volves  a  slower  process  of  dying.     At  times  we 


ANGINA   PECTORIS  141 

can  predict  the  near  approach  of  death,  but  in  the 
greater  number  this  is  impossible,  and  chiefly  for 
this  reason,  that,  even  when  the  cardiac  output  is 
greatly  diminished,  the  blood  pressure  does  not 
fall  fari  passu,  but  for  a  time  remains  normal  till 
the  fatal  limit  is  reached,  when  the  pressure  sud- 
denly falls,  and  death  ensues.^ 

Death  from  angina  is  thus  not  always  instanta- 
neous, nor  is  angina  always  fatal.  Angina  may 
even    be    recovered   from,    sometimes 

Elements  of 

perfectly,  for  when  the  cause  is  reme-  prognosis  in 
diable,  the  angina  is  also  curable.     At  ^'■^y^^^ 

.       .  pectoris. 

other  times  the  pain  is  removed,  but 
the  disease  progresses,  and  after  a  longer  or 
shorter  period  free  from  suffering,  or  with  only 
occasional  attacks  of  cardiac  asthma,  the  patient 
at  last  succumbs,  dying  of  angina,  no  doubt,  sed 
sine  dolore. 

In  endeavouring  to  get  a  basis  for  a  prognosis  in 
any  case  presenting  symptoms  indicative  of  angina, 
the  first  point  to  ascertain  is  whether  we  are  deal- 
ing with  a  true  angina,  or  merely  with  one  or 
other  of  the  varieties  of  neuralgia  referred  to  at 
page  117. 

In  the  absence  of  any  opportunity  of  observing 
a  seizure,  there  may  occasionally  be  some  difficulty 

1  Vide  Roy  and  Adami,  British  Medical  Journal,  December 
15,  1888,  p.  4  of  the  reprint. 


142  THE   SENILE  HEART 

in  deciding  this  matter.  Any  indication,  however 
slight,  of  dilatation  of  the  heart  must  be  looked 
upon  as  a  point  in  favour  of  the  reality  of  the 
angina,  and  this  at  any  age.  In  youth  the  proba- 
bility is  greatly  in  favour  of  this  dilatation  de- 
pending on  curable  spansemia,  and  therefore  of  the 
angina  itself  being  curable.  After  middle  life  Ave 
may  still  have  to  deal  with  a  curable  spansemia, 
though  the  dilatation  in  no  case  depends  solely  on 
this ;  and  the  next  point  to  determine  is,  have  we 
here  simple  senile  dilatation,  or  are  the  coronaries 
also  in  any  way  obstructed?  Atheroma  of  the 
external  arteries  affords  a  certain  presumption  in 
favour  of  the  coronaries  being  also  atheromatous ; 
but  even  if  they  are,  it  is  obstruction  and  not 
atheroma  that  induces  ischsemia,  and  the  question 
at  issue  can  only  be  decided  by  the  results  of 
treatment. 

On  the  other  hand,  if  there  be  uo  indication  of 
cardiac  dilatation,  —  which  is  but  seldom  the  case, 
—  an  anxious,  haggard  expression  unmistakably 
indicates  great  suffering  and  a  serious  disease, 
while  a  countenance  free  from  distress  or  anxiety 
is  an  equally  certain  indication  that,  whatever  may 
be  wrong,  we  have  not  to  deal  with  a  serious 
angina.  But  though  not  due  to  angina,  substernal 
pain  may  be  quite  as  dangerous  :  it  may  be  due  to 
a  small  aneurism  impossible  to  detect.     Such  cases 


ANGINA   PECTORIS  143 

are  great  sources  of  anxiety  to  the  physician,  and 
too  great  caution  cannot  be  exercised  in  giving 
any  decided  opinion  in  regard  to  them. 

The  large  reserve  of  energy  with  which  every 
heart  starts  in  life  enables  it  long  to  resist  the 
many  injurious  influences  to  which  it  may  be  ex- 
posed ;  hence,  considerable  enlargement  is  quite 
consistent  with  perfect  freedom  from  angina,  if 
the  arteries  are  pervious  and  the  blood  of  good 
quality ;  yet  such  a  heart  has  its  metabolism  easily 
upset,  and  comparatively  slight  causes  suffice  to 
induce  an  anginous  seizure.  There  is  little  won- 
der, then,  that  so  many  senile  hearts  are  subject  to 
angina ;  the  wonder  is  rather  the  other  way,  — 
that  there  are,  comparatively,  so  few  hearts,  even 
of  those  showing  decided  signs  and  symptoms  of 
cardiac  degeneration,  that  are  affected  by  this  com- 
plaint. Statistics  are  proverbially  uncertain,  and 
the  character  of  any  man's  experience  depends 
very  much  on  where  he  has  obtained  it,  so  I  give 
mine  only  for  what  it  may  be  worth,  without 
claiming  for  it  any  special  accuracy  in  regard  to 
any  one  particular. 

Confining  myself  solely  to  those  patients  who 
consulted  me  at  my  own  house,  during  the  ten 
years  1879-89,  I  find  that  I  have  notes  of  1173 
cases  of  various  affections  of  the  heart  and  aorta. 
Of  these,  581  were  senile  hearts,  270  were  young 


144  THE  SENILE  HEART 

spansemic  hearts,  and  only  57  were  cases  of  heart 

affection  distinctly  traceable  to  rheu- 

e  awe  pro-     .^2^\;^^Vi\^     Of  the  581  Senile  hearts,  98, 

portion  of  '        ' 

senile  to  other  or  rather  over  one-sixth,  made  a  prom- 
teZTandof  i^^^nt  complaint  of  angina.  Of  these, 
angina  to  the    17,  or  nearly  one-sixth,  were  females,  — 

senile  hearts.  •  i        i  i      i  i.*        xi, 

a  considerably  larger  proportion  than 
the  8  females  out  of  88  cases  collected  by  Sir  John 
Forbes,  but  the  number  is  still  sufficiently  small 
to  make  it  probable  that  Forbes  is  right  in  say- 
ing that  angina  is  more  common  in  men  than  in 
women ;  a  proposition  which  few  will  be  inclined 
to  deny.^ 

Of  the  98  cases  of  angina,  15  are  certainly  known 
to  have  died,  without  having  gained  anything  from 
treatment  beyond  palliation  of  the  symptoms ;  and 
17  are  known  to  have  got  entirely  free  of  their 
painful  seizures.  Of  these  17,  13  are  still  alive 
in  apparently  excellent  health,  and  4  have  died 
after  a  longer  or  shorter  period  of  complete  free- 
dom from  pain. 

One  of  these  patients  was  for  four  years  and  a 
half  completely  free  from  pain ;  during  this  period 

1  Cyclopedia  of  Practical  Medicine,  Vol.  i.,  p.  83.  But 
Forbes  adds :  "Of  milder  cases,  a  very  considerable  proportion, 
perhaps  an  equal  proportion,  are  met  witli  in  females,  and  at 
an  earlier  period  of  life.  This  at  least  is  the  result  of  our  own 
experience ;  and  the  same  opinion  is  entertained  by  writers  of 
great  authority." — Loc.  cit. 


ANGINA  PECTORIS  145 

he    progressed    from    sixty-nine    to   seventy-three 
years  of  age,  and  was  able  to  carry  on 

his  business,  attending"  markets  in  all      ^strattve 
'  °  cases. 

parts  of  the  country.  At  last,  after 
attending  market  in  the  country  town  in  which  he 
lived,  and  having  transacted  business  in  appar- 
ently perfect  health,  he  returned  home,  sat  down, 
and  without  a  complaint  quietly  departed.  When 
first  seen,  this  gentleman  had  suffered  from  angina 
for  eight  weeks,  and  attacks  came  on  whenever  he 
attempted  to  go  up  any  ascent,  and  the  pain  ex- 
tended into  both  arms,  but  chiefly  into  the  right 
one.  For  years  he  had  been  breathless ;  his  ar- 
teries were  all  atheromatous,  hard,  and  tortuous ; 
his  heart  was  dilated,  with  a  feeble  impulse,  and 
there  was  a  loud  systolic  murmur  in  all  the  cardiac 
areas.  Under  treatment,  the  pain  entirely  ceased 
in  a  few  months,  the  heart's  impulse  became  much 
stronger,  the  murmurs  less  distinct,  and  he  de- 
clared he  was  as  able  as  ever  to  go  up  hills  or 
stairs.  About  seven  months  before  his  death  he 
had  a  severe  fall,  and  was  never  so  well  after- 
wards. On  the  day  of  his  death  he  had  been 
about  his  business  all  day,  apparently  as  well  as 
ever  he  was;  he  went  out  again  in  the  evening, 
returned  about  half-past  seven,  sat  down,  and 
quietly  died.  After  death  his  face  was  pale,  with 
a  most  placid  expression,  his  pupils  were  both  nat- 


146  THE   SENILE  HEART 

ural.  There  was  no  post-mortem  examination  of 
the  body. 

A  second  case  was  that  of  an  old  gentleman, 
between  seventy  and  eighty  years  of  age,  who  Avas 
two  years  under  treatment  before  he  got  rid  of  his 
pain.  The  remedies  employed  gave  great  relief, 
but  the  pain  continued  to  recur  upon  exertion,  and 
sometimes  in  bed  if  his  stomach  was  flatulent,  for 
quite  two  years  ;  after  this  he  had  no  more  attacks 
of  pain.  When  first  seen  this  patient  had  a  feeble 
impulse,  and  a  loud  systolic  murmur  in  all  the 
cardiac  areas ;  when  last  seen,  just  a  week  before 
his  death,  his  apex-beat  was  firm,  the  systolic 
murmur  loud,  and  the  heart's  action  intermittent 
and  irregular.  His  arteries  were  very  hard  from 
the  first.  About  four  years  after  he  was  first  seen 
—  two  years  after  the  cessation  of  pain — he  had 
what  was  described  as  a  bad  faint ;  two  days  subse- 
quently he  had  another  slighter  attack  of  a  similar 
character,  but  no  pain ;  and  just  one  week  after- 
wards he  died  quietly  and  suddenly  one  forenoon, 
sitting  in  his  chair. 

The  third  case  was  that  of  a  fresh-looking  man 
of  sixty-one,  who  had  firm  arteries  with  high  blood 
pressure,  a  large,  dilated,  and  somewhat  liyper- 
trophied  heart,  with  considerable  palpitation  and 
irregularity  of  action.  He  had  severe  anginous 
pain   across   his   chest   upon   exertion,  extending 


ANGINA   PECTORIS  147 

down  the  right  arm.  The  urine  was  of  low  spe- 
cific gravity,  —  renal  inadequacy,  —  and  there  was 
an  occasional  trace  of  albumin.  He  had  also  long 
suffered  from  an  irritable  bladder  and  an  enlarged 
prostate  gland.  The  angina  was  speedily  relieved 
by  treatment ;  but  about  four  months  subsequently 
he  had  an  attack  of  pneumonia  of  no  great  severity, 
and  during  convalescence  he  died  somewhat  sud- 
denly from  urgemic  sinking. 

The  fourth  case  was  that  of  an  old  gentleman 
between  seventy  and  eighty,  who,  after  nearly 
ten  years'  relief  from  pain,  and  of  really  excellent 
health,  was  suddenly  seized  during  the  night  with 
an  attack  of  cardiac  asthma  and  died  in  about  half 
an  hour. 

Of  the  other  thirteen  who  got  rid  of  their  attacks 
of  pain,  some  have  been  free  for  quite  ten  years, 
others  for  varying  periods  down  to  five  years. 
Most  of  them  I  see  occasionally ;  the  rest  I  hear  of, 
and  I  know  them  to  be  well,  each  with  a  good  firm 
heart-beat  and  no  pain  on  exertion;  even  breath- 
lessness  is  not  much  complained  of,  though  where 
murmurs  did  exist  they  still  persist.  The  great 
difference  between  their  past  and  present  is  that 
whereas  their  hearts  were  formerly  feeble  and  ill 
fed,  they  are  now  strong  and  well  fed.  To  keep 
them  in  this  condition  they  require  constant  care, 
watching,  and  treatment,  and  in  the  face  of  advanc- 


148  THE   SENILE  HEART 

ing  age  none  of  these  can  be  long  pretermitted 
without  risk  of  a  serious  relapse. 

Of  the  fatal  cases  to  whom  treatment  gave  only 
temporary  relief,  two  were  little  over  middle  life ; 
both  were  busy  men.  In  the  first  of  these  the  apex 
beat  below  the  left  nipple ;  the  first  sound  was  almost 
absent,  quite  faint  and  impure ;  the  aortic  second 
was  accentuated ;  there  was  no  distinct  murmur 
anywhere  detectable ;  the  fits  of  angina  were  very 
severe  and  easily  brought  on.  I  saw  this  patient 
in  one  of  his  attacks,  and  formed  a  most  serious 
prognosis  from  the  severity  of  the  pain,  the  com- 
parative youth  of  the  patient,  and  the  little  that 
was  to  be  found  wrong  with  his  heart.  He  dropped 
down  dead  in  his  own  hall  about  a  month  after  I 
saw  him. 

The  second  patient  had  a  slight  systolic  murmur 
in  the  mitral  area ;  the  apex  beat  just  inside  the 
left  nipple ;  the  aortic  second  was  accentuated. 
The  fits  of  angina  were  said  to  be  very  severe,  but 
I  had  no  opportunity  of  seeing  one.  I  gave  an 
unfavourable  prognosis  for  reasons  similar  to  those 
given  in  the  former  case.  Three  months  subse- 
quently this  patient  was  found  dead  in  his  office. 

Three  patients  had  serious  illness  connected 
with  the  heart  for  some  weeks  before  death.  One 
of  these  was  never  well  after  his  first  attack  of 
angina ;   he  had  a  large,  dilated  heart,  and  died 


ANGINA   PECTORIS  149 

within  two  years.  The  other  two  were  country 
lawyers,  who  carried  on  their  arduous  business, 
one  of  them  for  ten  and  the  other  for  seven  years, 
subsequent  to  their  first  attack  of  angina ;  ^  both 
died  after  short  illnesses  following  overexertion  in 
the  course  of  business. 

One  clergyman,  after  suffering  for  about  seven 
years  from  a  dilated  heart  with  angina  on  exertion, 
hurried  to  catch  a  train  at  a  country  station,  and 
died  resting  in  a  chair  on  which  he  sat  down 
exhausted  when  he  reached  his  goal. 

Another  clergyman  had  been  out  for  a  drive  one 
bleak  November  day ;  on  coming  home  he  sat  down 
by  the  fire,  complaining  of  cold,  and  slipped  from 
his  seat  dead.  He  was  sixty-five  years  of  age,  and 
had  a  large,  dilated  heart,  with  a  shrill  systolic 
murmur  in  all  the  cardiac  areas.  He  died  within 
a  month  of  being  seen,  having  been  much  relieved 
by  treatment. 

A  third  clergyman  (each  of  these  was  of  a  differ- 
ent persuasion)  wrote  me  as  follows  a  few  weeks 
before  his  sudden  death ;  "  I  don't  know  whether 

1  As  I  was  writing  this,  the  son  of  one  of  these  lawyers,  a 
man  thirty-eight  years  of  age,  called,  complaining  of  angi- 
nons  pains,  on  exertion,  of  short  duration  and  not  severe.  His 
heart  was  weak,  its  sounds  parchmenty  in  character,  the  blood 
spanEemic  from  imperfect  recovery  from  an  attack  of  drain- 
poisoning  a  year  ago.  He  recognized  the  pain  as  similar  to 
what  his  father  had  suffered  from.     He  died  within  two  years. 


150  THE   SENILE  HEART 

you  will  remember  my  consulting  you  about  a  year 
ago.  .  .  .  As  long  as  I  keep  still  I  have  no  discom- 
fort, but  very  frequently,  though  not  always,  if  I 
walk  fifty  or  sixty  yards  I  am  seized  with  the  most 
painful  spasms,  not  in  my  heart,  but  in  the  pit  of 
the  stomach.  If  I  stand  up,  the  pain  comes  on ; 
even  putting  off  or  on  my  clothes  excites  it.  Yes- 
terday I  went  to  my  garden,  a  distance  of  less  than 
one  hundred  yards ;  I  had  severe  pain,  and  on 
coming  home  our  local  medical  man,  who  happened 
to  be  in  the  house,  found  my  pulse  to  be  inter- 
mittent; this  must  have  come  on  recently,  as  he 
never  observed  it  before.  I  am  seventy-one  years 
of  age,  and  with  the  exception  of  this  pain  I  am  in 
perfect  health,  and  feel  as  strong  and  well  as  I  was 
twenty  years  ago.  As  I  cannot  walk,  I  ride  or 
drive,  and  I  can  do  both  in  moderation,  provided 
I  enter  my  carriage  or  mount  my  horse  slowly,  but 
any  sudden  or  quick  movement  brings  on  discom- 
fort. Sometimes  I  am  for  a  week  quite  well,  and 
then  without  any  cause  which  I  can  trace  I  am 
suddenly  plunged  into  the  most  extreme  discomfort. 
A  brother  of  mine  suffered  for  some  time  from 
exactly  the  same  symptoms ;  he  was  told  he  was 
suffering  from  long-standing  heart  complaint.  For 
the  last  three  years  all  his  symptoms  have  dis- 
appeared, and  he  is  now  quite  well."  This  old 
clergyman  had  hard,  atheromatous  arteries,  a  large. 


ANGINA   PECTORIS  151 

dilated  heart,  with  a  systolic  murmur  in  all  the 
areas,  and  the  aortic  second  so  feeble  as  to  be  quite 
inaudible.  No  diastolic  murmur  was  to  be  heard. 
He  died  quite  suddenly  a  few  weeks  after  writing 
the  foregoing  letter;  no  treatment  gave  him  any 
relief. 

Other  four  angina  patients  of  the  ninety-eight 
referred  to  also  died  suddenly.  One  of  these  was 
a  case  of  free  aortic  regurgitation,  with  a  large 
heart ;  the  other  three  were  cases  of  dilated  heart, 
two  of  them  with  a  blunt  first,  an  accentuated 
aortic  second,  and  no  murmur ;  the  fourth  had  a 
large,  dilated  heart,  an  accentuated  aortic  sec- 
ond, and  a  systolic  murmur  in  all  the  areas. 
He  was  fifty-eight  years  of  age,  and  treatment 
gave  him  great  relief,  but  he  died  about  four 
months  after  being  first  seen.  One  morning  after 
breakfast  he  attempted  to  raise  himself  in  bed,  gave 
a  few  gasps,  and  died.  I  have  no  particulars  as 
to  the  mode  of  death  in  the  three  preceding 
cases. 

The  following  case  is  very  instructive  from  more 
than  one  point  of  view.  On  the  21st  of  January, 
1880,  I  was  asked  to  see  a  gentleman  suffering 
from  angina.  I  found  him  to  be  a  well-preserved 
man  of  sixty-eight,  suffering  so  much  that  the 
exertion  of  walking  even  ten  yards,  or  taking  off 
or  putting  on  his  clothes,  sufficed  to  bring  on  an 


152  THE   SENILE  HEART 

attack  of  pain,  distressing  enough,  but  not  of  great 
severity.  His  heart  was  slightly  enlarged;  the 
apex  beat  in  the  fifth  interspace  almost  directly 
below  the  left  nipple ;  the  first  sound  was  blunt, 
the  second  accentuated,  the  arteries  hard  and 
atheromatous.  I  prescribed  for  him,  and  recom- 
mended him  to  get  out  of  business,  and  if  possible 
into  a  warmer  climate.  As  he  had  already  suffered 
much  from  physicians,  I  gave  him,  at  his  own 
request,  the  following  letter,  to  show  to  any  physi- 
cian who  might  be  called  in,  the  view  taken  of  his 
case,  and  the  lines  on  which  it  was  desired  to  have 
the  treatment  carried  out. 

January  21st,  1880. 

Dear  Sir  :  I  shall  group  what  I  have  to  say  under  three 
heads : — 

1.  The  nature  of  your  disease  and  its  cause ; 

2.  The  treatment,  medical  and  general ;  and 

3.  The  results  to  be  expected  from  that  treatment. 

1.  The  cause  of  your  disease  is  primarily  a  loss  of  elastic- 
ity of  the  arteries ;  by  this  a  greater  strain  is  thrown  upon 
the  heart  than  usual.  The  result  of  this  extra  strain  is,  in 
your  case,  a  slight  enlargement  of  the  heart  —  dilatation  with 
compensatory  hypertrophy.  In  your  case  the  hypertrophy 
is  somewhat  insufficient,  and  the  result  is  that  when  your 
heart  is  called  upon  for  any  unusual  exertion,  either  by  emo- 
tion or  bodily  exercise,  it  becomes  pained,  and  the  pain 
shoots  along  the  course  of  various  nerves  connected  with 
those  of  the  heart,  and  thus  gets  referred  to  various  other 
parts,  as  the  arms  or  stomach,  after  a  fashion  with  which 


ANGINA   PECTORIS  153 

medical  men  are  only  too  well  acquainted.  In  its  essence  it 
is  an  angina  pectoris,  not  associated  with  a  lesion  of  any 
valve,  though  I  quite  believe  that  the  signs  of  mitral  regur- 
gitation may  sometimes  be  present. 

2.  The  medical  part  of  the  treatment  resolves  itself  into 
means  to  relieve  the  pain  when  it  occurs ;  and,  secondly,  the 
use  of  remedies  to  improve  the  condition  of  the  heart,  and 
thus  lessen  the  frequency  of  the  attacks.  These  prescrip- 
tions will  be  found  on  a  separate  paper,  and  on  it  the  medi- 
cal man,  whom  you  must  always  send  for  at  once  on  the 
occurrence  of  any  seizure,  will  also  find  noted  down  sugges- 
tions as  to  certain  supplementary  measures  which  may  be 
employed  if  the  attack  does  not  quickly  yield  to  the  means 
first  employed.  The  general  treatment  must  consist  in  a  per- 
sistent avoidance  of  all  bodily  or  mental  excitement.  You 
should,  therefore,  go  about  on  foot  as  little  as  possible  ;  at 
present  drive  only.  Shun  all  public  meetings  and  worry  of 
every  kind.  To  gain  this  complete  rest  of  body  and  mind, 
as  well  as  to  escape  our  often  severe  cold,  which  for  you  is  not 
devoid  of  danger,  I  would  strongly  recommend  you  to  start 
at  once  for  the  south  of  England  at  least,  and  if  at  all  able, 
for  the  south  of  France.  I  have  no  doubt  that  you  will 
benefit  greatly  by  the  change,  and  I  think  you  will  manage 
it  comfortably,  taking  the  journey  by  easy  stages. 

3.  The  amount  of  benefit  you  are  to  expect  from  treatment 
depends  upon  conditions  as  yet  unknown  to  me,  but  which 
will  reveal  themselves  by  and  by.  What  I  aim  at  is  to  put 
on  the  drag,  so  as  to  stop  you  from  going  down  hill  so  rapidly 
as  you  have  been  doing.  If  your  heart  muscle  is  as  sound 
as  I  believe  it  to  be,  the  treatment  may  result  in  completely 
stopping  the  pain ;  more  probably,  from  the  long  time  the 
pain  has  already  troubled  you,  it  will  only  come  seldom er  and 
be  less  severe.  The  causes  of  your  ailment  are  incurable  ;  we 
can  only  mitigate  the  results.  Sometimes  the  relief  obtained 
is  so  great  as  to  simulate  a  perfect  cure,  and  this  is  what  we 
aim  at.     I  am,  etc. 


154  THE   SENILE  HEART 

The  following  December  I  wrote  the  patient's 
doctor  to  enquire  as  to  his  condition,  and  received 
the  following  reply :  "  I  saw  Mr.  B.  about  two 
months  ago,  and  found  him  in  excellent  health. 
I  believe  he  is  at  business  every  day,  and  able  for 
a  good  day's  work.  After  you  saw  him  with  me 
in  spring  he  went  to  Bournemouth,  with  which  he 
was  delighted.  He  stayed  there  three  months,  and 
came  home  in  June  immensely  improved  in  every 
way.  No  return  of  the  angina  pectoris,  nor  any 
tendency  thereto,  since  you  last  saw  him.  July 
and  August  he  spent  at  Crieff,  and  thought  this 
also  helped  him  greatly.  When  I  examined  him 
in  June,  there  was  still  evidence  of  the  dilatation 
of  the  heart,  but  I  could  make  out  no  murmur. 
His  breathing  power  was  also  much  improved ;  he 
could  walk  much  farther,  without  ever  requiring  to 
stop  as  formerly." 

Early  in  the  following  March  Mr.  B.  paid  me 
another  visit ;  he  assured  me  that  so  far  as  he  could 
judge  he  was  as  well  as  ever  he  was,  and  that  he 
had  only  called  to  obtain  my  sanction  to  his  mar- 
riage, as  he  thought  an  agreeable  companion  would 
greatly  conduce  to  his  comfort  and  happiness. 

I  found  the  heart's  impulse  much  improved  in 
strength,  otherwise  the  condition  of  the  heart  was 
as  formerly,  and  my  sanction  to  his  marriage  was 
given  along  with  some  sage  advice.     After  this 


ANGINA   PECTORIS  155 

Mr.  B.  continued  in  the  enjoyment  of  apparently 
perfect  health  for  about  two  years.  Then  his  part- 
ner in  business  died  rather  suddenly,  and  as  this 
partner  had  for  some  years  taken  the  larger  share 
in  conducting  their  very  extensive  business,  the 
whole  of  this,  with  all  the  correspondence,  was  sud- 
denly thrown  upon  Mr.  B.  The  result  was  a  com- 
plete breakdown;  the  work  and  worry  were  too 
much  for  his  heart;  this  organ  rapidly  dilated,  it 
developed  a  loud  systolic  murmur  in  all  the  areas, 
its  action  became  embarrassed,  very  considerable 
general  dropsy  set  in,  and  the  case  looked  most 
serious.  Fortunately,  the  recuperative  power  of 
the  heart  was  not  lost ;  it  responded  well  to  treat- 
ment, and  a  few  weeks  of  perfect  rest  restored 
Mr.  B.  again  apparently  to  his  former  state.  His 
health  seemed  quite  re-established,  he  suffered  no 
more  from  his  heart,  and  he  was  able  to  go  about 
and  enjoy  himself,  though  debarred  from  any 
longer  taking  an  active  share  in  business.  Two 
years  more  passed  away,  and  again  I  saw  Mr.  B., 
this  time  for  a  slight  paralysis  affecting  the  left 
arm,  apparently  due  to  some  cortical  thrombosis 
or  small  embolism.  This  paralysis  came  on  with 
giddiness  as  he  was  leaving  church  one  Sunday 
afternoon ;  it  speedily  passed  away,  and  left  him 
not  a  whit  the  worse.  Six  months  afterwards  he 
died  from  pneumonia.    Being  from  home,  I  did  not 


156  THE   SENILE  HEART 

see  him  upon  this  occasion,  but  I  understand  that 
his  damaged  heart  undoubtedly  hastened  his  end. 
It  is  the  rarest  thing  in  the  world  —  if  indeed  it 
ever  happens  —  for  a  man  over  sixty,  with  a  di- 
lated heart,  to  recover  from  pneumonia.  Even  if 
he  recovers  from  the  primary  attack,  the  exhaus- 
tion following  it  initiates  the  beginning  of  the  end, 
which  is  no  long  time  in  following. 


CHAPTER   VII 

THE   SENILE   HEART,    ITS    CONCOMITANTS,    AND 
SEQUELS.      GOUT 

Latham  has  finely  said  that  the  clinical  history 
of  diseases  of  the  heart  is  but  the  history  of  "  those 
prior  and  accompanying  conditions  in  the  life  and 
health  of  the  patient,  which  were  found  variously 
leading  to  and  variously  promoting  and  causing 
them ;  as  well  as  all  those  subsequent  conditions 
in  the  life  and  health  of  the  patient  variously 
springing  from  them  and  variously  promoted  and 
caused  hy  them."  And  Latham  adds  that  the 
treatment  of  such  diseases  is  but  the  employment 
of  "means  of  influencing  those  same  conditions 
and  of  influencing  them  for  good."  ^ 

These  statements  —  so  true  of  all  cardiac  dis- 
eases —  find  their  pre-eminent  application  in  senile 
affections  of  the  heart.  For  the  clinical  history 
of  these  affections  is  not  the  mere  story  of  the 
past  few  weeks,  but  comprises  the  life-history  of 

1  Latham,  op.  cit..,  Vol.  ii.,  p.  360. 
157 


158  THE   SENILE  HEART 

the  patient  from  his  cradle  to  his  grave,  and  often 
^,  ,      includes   that  of  his  forefathers   also. 

The  story  of 

senile  cardiac    They  form  part  and  parcel  of  the  pa- 
diseasecom-      ^^gj-^^'g  development,  and  are  the  natural 

prehends  the  ^ 

lohoie  life-        result  of  prematurity,  or  of  excess,  in 
story  of  the       ^^iose  chauffcs  affectinpf  the  arterial  tis- 

pat lent  from  °  ° 

his  cradle  to  sue  whicli  wait  upon  advancing  years, 
isyiave.  ^^^^  which  in  their  turn  variously 
modify  every  subsequent  condition  in  life.  These 
tissue  changes  commence  long  previous  to  the  time 
when  either  symptoms  or  organic  changes  force 
themselves  upon  the  attention  of  patient  or  physi- 
cian. During  all  this  time  they  have  been  slowly 
but  persistently  exerting  a  modifying  influence,  not 
alone  upon  any  one  organ  of  the  body,  but  on  every 
tissue  of  which  the  body  is  composed,  as  well  as 
on  every  function  which  its  organs  discharge. 

The  arterial  dilatation,  already  referred  to,  which 
results  from  the  loss  of  elasticity,  coupled  with 
lessening  of  the  capillary  area  from  obsolescence 
of  many  of  these  vessels,  gradually  induces  another 
change  in  the  circulatory  system  too  often  forgotten 
or  overlooked,  but  which  is  yet  a  factor  in  every 
function  of  our  future  life  important  enough  to 
demand  our  most  serious  attention. 

Up  to  the  completion  of  puberty  the  pulmonary 
artery  is  larger  than  the  ascending  aorta;  with 
the  advance  of  maturer  years,  and  the  coincident 


ITS   CONCOMITANTS  AND   SEQUELS  159 

changes  in  the  circulatory  system,  a  change  takes 
place  in  the  relative  size  of  these  ves- 
sels.^    The  effects  of  this  change  are  relative  size  of 
of  the  greatest  importance.     So  long  the  pulmonary 

.  artery  and  the 

as  the  pulmonary  artery  remained  the  aorta  takes 
larger  of  the  two,  the  blood  within  the  ^^«^«  ^^^^^ 

viiddle  life. 

pulmonary  circulation  was  kept  at  a 
high  pressure,  and  this  notwithstanding  a  free  and 
unembarrassed  egress  into  the  left  heart,  and  so 
onwards.  But  blood  circulating  through  the  lungs 
at  a  high  pressure,  and  at  the  normal  rate,  gets  rid 
of  its  carbonic  acid  more  rapidly  and  also  more 
perfectly  than  blood  circulating  at  the  same  rate 
but  at  a  lower  pressure.  Hence  up  to  nearly 
middle  life  every  tissue  of  the  body  has  been  con- 
tinuously flushed  with  a  highly  oxy- 
genated blood,  full  of  potentiality,  and  f-^'f'  ^-^^    , 

^  ••-  "^  high  intra-pid- 

a  well-nourished  and  healthy  organism  monary  blood 
has  thus  been  filled  full  of  life  and  pJ^''^'^'' 

health. 

vigour,  and  placed  at  its  very  best  in 
regard  to  capacity  for  bodily  and  mental  exertion. 
After   the  full   development   of   puberty  all  this 
slowly  changes;  under  the  influences  already  de- 

1  Vide  Beneke,  Die  Altersdisposition,  Marburg,  1879,  S,  18. 
Also  "Ueber  das  Volumen  des  Herzens  und  die  Weite  der 
Arteria  pulmonalis  und  Aorta  ascendens  in  den  verscliiedenen 
Lebensaltern."  In  Schriften  der  Gesellschaft  zur  Beforderung 
der  gesammten  Naturwissenschaften  zu  Marburg,  Cassel,  1879, 
S.  5. 


160  THE   SENILE  HEART 

tailed  (vide  antea^  p.  11,  etc.)  the  calibre  of  the 
aorta  becomes  gradually  greater  than  that  of  the 
pulmonary  artery.  The  result  of  this  relative 
diminution  in  the  size  of  the  pulmonary  artery  is 
that  the  blood  circulates  through  the 
Effects  of  a       i^npfs  at  a  much  lower  pressure  than 

low  mtra-pul-  °  ^ 

monary  blood    formerly,  the   carbonic  acid  is  conse- 

presswrem  quently  given  off  more  slowly,  and 
throughout  all  the  future  life  there  is 
a  gradually  increasing  "  venosity  "  of  the  blood,  as 
the  older  writers  called  it,  which  has  an  important 
influence  on  every  function  of  the  body.  As  age 
advances  there  is  also  a  slowly  increas- 
latory  changes  ^^^  tendency  of  the  blood  to  accumulate 
coincident        ^ci  the  vcins  at  the  expense  of  that  con- 

with  this.  .       ,  .       ,  .  ,     ,        , .    , 

tamed  m  the  arteries,  and  the  slightest 
disposition  to  cardiac  debility  aggravates  this  ten- 
dency. The  result  of  this  is  an  increasing  disposi- 
tion to  venous  congestion,  to  remora  of  the  blood  in 
the  venous  radicles,  and  also  to  accumulation  of  the 
serous  plasma  in  the  extra-vascular  spaces.  The 
influence  of  the  increased  tension  thus  produced 
within  these  spaces  upon  the  intra-vascular  blood 
tension,  and  through  that  upon  the  heart,  has  been 
alread}?"  referred  to  (vide  antea,  p.  28).  We  shall 
presently  see  that  this  extra-vascular  remora  of  the 
blood-plasma  also  forms  an  element  in  one  very 
important   disease,  and  often  gives  rise   to  local 


ITS   CONCOMITANTS  AND   SEQUELS  161 

morbid  phenomena  of  an  interesting  if  not  danger- 
ous character. 

Thus,  after  middle  life,  the  blood  is  being  con- 
tinually shut  off  from  ever-increasinP" 

•^  _        °    Effects  of  these 

areas  throughout  the  body  by  wither-  vascular 
ing-  of  the  capillaries ;  it  slowly  accu-  ^^^y^^  ^^ 

^  ,         ^  ^    ,  the  blood. 

mulates  in  the  veins,  it  is  less  highly 
oxygenated  than  formerly,  and  is  thus  less  fitted 
for  promoting  the  discharge  of  any  of  the  vital 
functions. 

But  this  condition  of  "  venosity "  of  the  blood, 
and  of  remora  of  the  blood  in  the  veins,  —  "  venous 
congestion,"  as  it  is  so  usually  termed,  —  has  been 
recognized  by  all  physicians  since  the  days  of  Galen 
as  "the  first  condition  essential  to  the  formation 
of  the  gouty  diathesis."^  It  is  the  basis  of  that 
diathesis. 

Add  to  this  that  in  a  state  of  civilization  man 
is  always  supplied  with  a  superfluity 
of  foods  and  drinks,  which  the  habits  5'^^  «^.^^^;«- 

'  tions  in  the 

of  society  and  the  anxiety  of  his  friends  Mood  resulting 
tempt  him,  if  they  do  not  actually  com-  •'^^J^  ^hcmTs' 
pel  him,  to  partake  of  four  or  even  are  the  basis 

XX        J-'  J  of  the  gouty 

live  times  a  day.  ,.  ^,  ^.     ^ 

«^  diathesis. 

Moreover,  as  the  bubbling  energy  of 
youth  fails,  the  mere  pleasure  of  it  no  longer  in- 
cites us  to  violent  exertions,  the  needs  of  civiliza- 

1  On  Gout.     By  W.  Gairdner,  M.D.,  London:  1849,  p.  121. 

M 


162  THE  SENILE  HEART 

tion  do  not  require  such  exertions  from  us,  and 
the  many  luxurious  appliances  of  civilized  life  aid 
and  abet  the  natural  indolence  that  grows  upon 
man  as  age  advances,  and  largely  preclude  the 
need  for  any  but  the  most  trifling  bodily  exer- 
tion. 

Hence  this  less  highly  oxygenated  blood  is 
flooded  with  a  redundancy  of  nutritive  material, 
far  in  excess  of  the  requirements  of  the  frame, 
which  can  neither  be  used  up  in  any  of  its  ordinary 
appropriations,  nor  fully  oxidated  in  any  other 
way,  and  so  excreted.  The  general  metabolism 
is  thus  impaired,  every  function  of  the  body  im- 
peded, every  secretion  deteriorated ;  all  the  organs 
suffer. 

Thus  we  have  the  Gouty  Diathesis  fully  devel- 
oped ;  a  diathesis  —  habit  of  body  —  present  in 
each  one  of  us  after  middle  life,  and  which  modi- 
fies the  organic  metabolism  of  each  one  of  us,  both 
in  health  and  in  disease.  The  gouty  diathesis  is 
only  a  comprehensive  term  for  all  those  changes 
in  the  character  and  composition  of  the  blood  in- 
duced by  the  evils  of  civilization — deficient  exer- 
cise and  excess  of  nutriment — ^multiplied  into 
those  developmental  changes  in  the  vascular  sys- 
tem, which  are  at  once  the  cause  and  also  the  con- 
sequent of  puberty. 

Gout,  on  the  other  hand,  is  the  name  given  to 


ITS   CONCOMITANTS  AND   SEQUELM  163 

all  those  modifications  of  our  metabolism  caused 
by  the  gouty  diathesis,  as  well  as  to   g,^^,^^^y^ 

all  the  symptoms  to  which  those  modi-    generic  term 

fications   give   rise.      Naturally,   after  "^fjf^'^,;^. 

middle   life  gout   affects   every  organ  coxion^  of 

of  the  body,  both  m  its  structure  and  ^^^^^^  ^^  ^^^ 

its  function ;  in  a  state  of  civilization  gouty  dia- 

we  are  all,  after  puberty,  more  or  less 

gouty,  and  we  are  gouty  in  a  gradually  increasing 

ratio. 

A  paroxysm  —  painful  and  distressing  though  it 
be  —  is  a  mere  episode  in  the  history  of  gout,  and 
an  episode  indeed  to  which  not  a  tithe 

/.      1  1  •    1  1  rrn  ^  paroxysm 

of  the  gouty  are  liable.      The  sever-  of  gout  is  a 
itv  of  the  symptoms  are  but  an  acci-  ^^^f^  episode 

*'  '^^'^  its  Tiisfow * 

dent  of  locality ;  and  the  pain  like  that 

of  angina   pectoris   itself  is  but   the   product   of 

ischsemia. 

It  is  many  a  year  ago  since  Cullen  rejected  the 
term  Arthritis  as  inapplicable  to  the  gouty  parox- 
ysm, because  it  hinted  at  an  inflammation  which 
had  no  existence,  and  gave  it  the  name  of  Podagra^ 
as  expressive  of  the  one  fact  most  undeniable 
about  it,  that  though  it  may  occasionally  affect 
other  parts,  it  is  most  usually  a  severe  pain  in  the 
foot.i  Cullen's  description  of  an  attack  is  still 
as  accurate  as  ever,  and  the   appearance  of   the 

1  Synopsis  Nosologies,  Methodicce,  Edin.,  1815,  p.  17,  note. 


164  THE   SENILE  HEART 

part  affected  is  the  same  now  as  then,  yet  we 
seem  to  have  made  but  little  progress  in  discover- 
ing its  true  nature. 

If  there  is  one  thing  more  certain  than  another 
about  an  acute  gouty  affection  of  a  joint,  it  is 
^.  ,.    ,.  that,  thousfh  often  regarded  as  an  in- 

marks  of  a  flammation,  it  presents  none  of  the 
gouty  join .  characteristics  of  that  process,  and 
ends  in  none  of  its  usual  terminations.  There  is 
never  any  suppuration,  and  never  any  adhesion  of 
the  opposed  surfaces.     There   is  here 

Never  any  ^  ^ 

adhesion  or  no  process  of  abnormal  nutrition,  no 
suppuration,  cell-proliferation,  no  diapedesis  of  the 
white  cells,  no  true  inflammation. 

It  may  be  objected  that  a  gouty  joint  always 
ends  in  resolution,  and  that  resolution  is  one  of 
„     ,  ,.       ,    the  natural  terminations  of  inflamma- 

Resolution  al- 
ways incom-      tiou.     But  the    resolution  of  a  gouty 

^  ^  ^'  joint  is  always  incomplete  ;  even  after 

a  first  attack  there  is  left  behind  a  deposit  of  urate 

of  soda  in  and  around  the  joint,  and  this  increases 

with  each  subsequent  attack,  so  that  a  gouty  joint 

never  returns   to   its  pristine  condition,  but  gets 

larger  and  stiffer  with  each  attack. 

Again,   of  the   well-known    Quatuor   Notce^   the 

Color  is  often,  if  not  always,  Avanting ; 


Calor  loant- 

may  even  be  below  the  normal.      ''I 


the  temperature  of  the  affected  ioint 

tng.  •*■  *• 


ITS   CONCOMITANTS  AND   SEQUELS  165 

have  found  it  97,  while  that  in  the  mouth  at  the 
same  time  was  100."  ^  This  is  quite  incomprehen- 
sible except  on  the  supposition  that  there  is  some 
obstruction  to  the  free  circulation  of  the  pyrexial 
blood  through  the  part  affected,  and  indeed  the 
whole  history  of  a  paroxysm  is  most  readily  expli- 
cable upon  this  supposition,  while  at  least  one  kind 
of  treatment  is  quite  inexplicable  upon  any  other. 
A  paroxysm  begins  with  a  sudden  attack  of 
acute  pain,  which  may  pass  off  as  sud- 

11  • ,  1         •  lA        '    '    X.    History  of  a 

denly    as   it   came,  leaving   the  jomt  ^(.^^a^/sm. 
unaltered;  or  the  pain   may  increase, 
and  become  excruciating;  the  joint  swells,  becomes 
dusky  red,  tense  and  shining,  and  the  veins  lead- 
ing from   the  ioint  to  the  dorsum  of 

Dark  turgid 

the  foot  are   dark   and   turgid.     The  veins  leak  off 
attack    g-enerally   beofins   with    sligfht  ^^^^  ^^^  ^^^* 

.  .        .  affected. 

shivering;  the  pain  is  compared  to 
that  of  a  penal  boot  or  thumb-screw ;  this  torture, 
made  unbearable  by  the  slightest  vibration,  lasts 
till  morning  —  till  cock-crow,  galli  cantu^  as 
Sydenham  puts  it;  then  slight  remission  takes 
place,  the  patient  falls  into  a  gentle  perspiration, 
and  at  last  gets  to  sleep.  In  the  morning  the 
joint  is  found  swollen,  shining,  dusky  red,  and 
the  pain  is  easier.     This  remission  lasts  through 

1  Vide  Sir  Dyce  Duckworth's  Treatise  on   Gout,  London, 
1889,  p.  248. 


166  THE   SENILE  HEART 

the  day,  but  towards  evening  the  pain  recurs  as 
severe  as  ever,  and  this  cycle  of  remission  and 
exacerbation  goes  on  for  four  to  eight  nycthemera. 
Then  the  crisis  is  over,  the  remissions  get  gradu- 
ally longer  and   more   complete,  and 

Paroxysm  ^  o 

may  last  from  erelong   there   is   nothing    left  but  a 

afortnifjht  to    numbness  which    may  last  for   about 

three  weeks.  ^ 

a  week.  The  redness  of  the  joint 
attains  its  maximum  intensity  in  about  thirty 
hours ;  it  then  diminishes  or  rather  gets  more  vio- 
let in  hue  as  the  pain  wears  away.  The  oedema 
increases  for  four  or  five  days,  and  when  it  disap- 
pears and  the  attack  is  over  the  joint  remains  stiff, 
.the  foot  soft  and  numb,  and  the  gait  hesitating  for 
other  ten  or  fifteen  days. 

Throughout   the  whole  history  of  a  paroxysm 

A  paroxysm      *^^^'®    ^^    ^^    indication    whatever    of 
of  gout  not  an  inflammation  ;   there  is  no  known  in- 

injlammation.    n  ,  •  ^  •   ^  n       -\  ^ 

nammation  which  runs    so   nxed  and 

definite  a  course,  and  so  invariably  terminates  in 

resolution. 

On  the  other  hand,  if  we  accept  the  idea  of  the 

grouty  ioint   being^    an  infarctioji.    the 
Infarction  ^        J    -^  t>   ^  J    ^ 

suggested  as      phenomena  are  easily  explicable,  and 

an  expiana-  ^j^q  invariable  termination  readily  ac- 
tion of  the 

condition  of  counted  for. 

the  gouty  j^^   infarction  is  the   P-ormno:   of  a 

joint,  ,  o      »      o  ^ 

part   with   serum,   blood,   or   both;    it 


ITS   CONCOMITANTS  AND   SEQUELS  167 

presupposes  a  block  in  the  circulation,  the  forma- 
tion of  an  ansemic  area,  and  the  gorging  of  this 
area  with  retrograde  blood  from  the  neighbouring 
valveless  veins.^ 

There  is  no  difficulty  in  imagining  the  occur- 
rence of  a  block  in  the  circulation  of  any  gouty 
person,  as  we  know  gouty  thrombosis  to  be  in 
them  a  very  common  occurrence.  Recumbency 
for  a  few  days  for  some  trifling  ailment  is  quite 
sufficient  to  induce  thrombosis  in  one  or  more  of 
the  veins  of  the  extremities  in  many,  necessitat- 
ing three  weeks  longer  in  bed  than  was  bargained 
for.  In  others,  some  unusual  sedentariness  of 
occupation  is  quite  sufficient  to  cause  thrombosis, 
which  gives  rise  to  no  pain  unless  it  be  connected 
with  some  tendinous  part  such  as  the  heel,  where 
indeed  it  is  but  slight  and  evanescent,  as  it  some- 
times is  when  it  occupies  but  a  limited  area  even 
in  the  usual  point  of  selection,  the  junction  of  the 
metatarsal  bone  with  the  proximal  phalanx  of  the 
great  toe. 

Granted  the  block  in  the  circulation,  then  the 
other  phenomena  follow  in  regular  sequence  as 
a  matter  of  course.  Arrest  in  the  onward  move- 
ment of  the  blood  in  the  veins  leading  from  the 
part  is  speedily  followed  by  their  turgescence, 
because  the  blood  flows  into  them  from  the  sur- 
1  Cohnheini,  op.  cit.^  p.  121. 


168  THE   SENILE  HEART 

rounding  capillaries  and  valveless  veins  until  an 
equilibrium  is  established  between  the  pressure 
in  the  occluded  area  and  that  within  these 
veins.^ 

The  sluggish  movement  of  the  blood  also  per- 
mits the  accumulation  of  the  red  corpuscles  within 
the  capillaries  of  the  affected  area,  hence  the  red 
turgescence  of  the  part,  a  redness  that  grows 
duskier  the  longer  it  continues. 

Moreover,  the  remora  of  the  lymph  within  the 
tissue  interspaces  not  only  contributes  to  the 
tension  of  the  part,  but  the  lymph  being  highly 
charged  with  the  somewhat  insoluble  salts  of  uric 
acid,  these  may  crystallize  out  during  this  delay, 
or  they  may  get  left  behind  as  a  residuum  when 
the  lymph  gets  reabsorbed  as  recovery  progresses, 
and  thus  originate  those  deposits  of  urates  in  and 
around  the  joint  which  increase  with  each  subse- 
quent attack. 

The  pain  is  in  the  later  stages  largely  augmented 
by  the  increased  tension  within  the  part,  but  pri- 
marily it  is  due  to  ischsemia.  An  acute  twinge 
is  often  the  earliest  indication  of  an  attack,  this 
goes  on  increasing  if  the  other  signs  are  super- 
added, but  the  pain  passes  off  at  once  should  the 
circulation  rapidly  return  to  its  normal,  as  it  not 
infrequently  does. 

1  Cohnheim,  loc.  cit. 


ITS   CONCOMITANTS  AND   SEQUELS  169 

In  favour  of  the  idea  that  a  gouty  paroxysm  is 
due  to  a  local  infarction,  we  have  thus,  — 

First.  A  gouty  joint  contains  no  inflammatory 
exudation,  but  merely  a  sero-sanguinolent  effusion 
in  and  around  the  joint ;  and  neither  in  its  com- 
mencement, course,  nor  termination  does  it  cor- 
respond with  any  known  form  of  inflammation. 

Second.  In  the  gouty  diathesis  thromboses  are 
common  enough ;  they  occur  in  circumstances  and 
under  conditions  precisely  similar  to  those  in 
which  we  have  a  paroxysm  of  gout  evolved,  but 
a  gouty  paroxysm  never  follows  unless  the  throm- 
bosis happens  to  occupy  a  position  in  which  it 
necessitates  the  formation  of  an  infarction. 

Third.  When  a  thrombosis  occurs  anywhere, 
the  time  occupied  in  recovery  is  precisely  the  same 
as  that  usually  required  for  recovery  from  a  fit  of 
gout.  I  well  remember  an  old  friend  who  was 
subject  to  repeated  attacks  of  gouty  aphasia  due 
to  cerebral  thrombosis ;  in  him  the  period  that 
elapsed  before  the  power  of  speech  returned  was 
three  weeks,  —  precisely  that  usually  occupied  by 
an  ordinary  fit  of  gout. 

Fourth.  The  acceptance  of  thrombosis  followed 
by  infarction  as  an  efficient  cause  of  the  gouty 
paroxysm,  not  only  affords  a  reasonable  and  suffi- 
cient explanation  of  all  the  concomitant  phenomena 
of  a  fit  of  gout,  but  it  also  supplies  a  rational  and 


170  THE   SENILE  HEART 

intelligible    explanation  of   a  mode    of   treatment 

which  has  proved  highly  successful,  and  which  is 

utterly  inexplicable  in  any  other  way. 

When    Boerhaave   in    Section   3  of   his  1275th 

aphorism  talks  of  the  cure  of  gout  being  carried 

out,  "  Exercitio  magno^  continuato  equl- 

cu  er/ou         tationibus  in  cere  puro,  turn  frictionihus^ 
may  he  sue-  x'         7  »/  7 

cessfuiiy  motibusque  partium  scepe  iteratis^^^^  it  is 

trea  ec    y         quite  probable  from  the  context  that 

massage  alone.    ^  -t^ 

he  refers  to  the  cure  of  an  acute  attack, 
and  not  merely  to  massage  and  other  forms  of 
friction  as  employed  to  remove  the  rigidity  of  gouty 
limbs. 

At  all  events  we  know  that  Sir  William  Temple 
—  who  was  ambassador  at  the  Hague  when  Boer- 
haave was  born  —  was  aware  of  this  method  of 
cure,  for  he  says  that  in  one  part  of  the  East 
Indies,  "the  general  remedy  of  all,  that  were 
subject  to  the  gout,  was  rubbing  with  hands ;  and 
whoever  had  slaves  enough  to  do  that  constantly 
every  day,  and  relieve  one  another  by  turns,  till 
the  motion  raised  a  violent  heat  about  the  joints 
where  it  was  chiefly  used,  was  never  troubled 
much,  or  laid  up  by  that  disease."  ^     Temple  also 

1  Aphorismi  de  cognoscendis  et  curandis  morhis,  ab  Her- 
manno  Boerhaave,  ed.  8tia,  Lugdun,  Batavorum,  1727,  p.  312. 

2  Boerhaave  was  born  in  1669  ;  Temple  retired  from  the 
embassy  in  1671.  Vide  An  Essay  on  the  cure  of  gout  by  Moxa, 
in  The  Works  of  Sir  William  Temple,  Bart.  Edinburgh,  1754. 
Vol.  ii.,  p.  127. 


ITS   CONCOMITANTS  AND   SEQUELM  171 

says  that  the  Rhyngrave,  whom  he  knew  very  well, 
never  used  any  other  remedy  for  the  gout,  to 
which  he  had  long  been  subject,  except  on  the  first 
indication  "  to  go  out  immediately  and  walk,  what- 
ever the  weather  was,  and  as  long  as  he  was  able 
to  stand,  and  pressing  still  most  upon  the  foot  that 
threatened  him ;  when  he  came  home  he  went  to 
a  warm  bed,  and  was  rubbed  very  well,  and  chiefly 
upon  the  place  where  the  pain  began.  If  it  con- 
tinued or  returned  next  day,  he  repeated  the  same 
course,  and  was  never  laid  up  with  it ;  before  his 
death  he  recommended  this  course  to  his  son,  if 
ever  he  should  fall  into  that  accident."  ^  Temple 
also  tells  of  one  of  his  brother's  gamekeepers  who 
when  seized  by  a  fit  of  gout  never  laid  himself  up, 
but  walked  after  his  deer  or  his  stud  from  morning 
to  night,  in  spite  of  the  pain,  till  he  got  ease.^ 
This  reminds  us  of  the  statement  by  Mr.  Apperley 
—  the  well-known  Nimrod  of  old  days  —  that  a 
friend  of  his  when  threatened  with  a  fit  of  gout, 
after  a  good  dinner  and  his  quantum  suff.  of  wine, 
warded  it  off  by  walking  the  soles  of  his  pumps 
quite  through  before  going  home  to  bed.  Dr. 
Gairdner  also  relates  the  case  of  a  friend  of  his 
own,  an  old  gentleman  of  eighty-five,  whose  con- 
stant remark  to  his  physician  and  his  family  when 
he  was  seized  with  a  fit  of  gout,  was,  "  I'll  walk 
1  Loc.  cit.  2  £qc^  qh^ 


172  THE   SENILE  HEART 

it  off  " ;  and  walk  it  off  he  did.  This  same  old 
gentleman  often  quaintly  remarked  to  his  friends^ 
"  Go  to  bed  with  the  gout,  and  it  will  surely  go 
to  bed  with  you,  and  be  mighty  bad  company "  ^ 
—  a  statement  which  curiously  resembles  that  by 
Temple  that  sufferers  from  gout  carry  it  presently 
to  bed,  and  keep  it  safe  and  warm,  and  indeed  lay 
up  the  gout  for  two  or  three  months,  while  they 
give  out,  "that  the  goat  lays  up  them."^ 

In  the  beginning  of  this  century  a  namesake  of 
my  own,  apparently  quite  unaware  that  anything 
had  ever  been  written  in  regard  to  the  treatment 
of  acute  gout  by  friction,  wrote  a  paper  on  what 
he  called  a  "  New,  simple,  and  expeditious  method 
of  curing  gout,"  ^  advocating  massage  for  this 
purpose.  He  narrates  three  cases  in  which  this 
treatment  was  perfectly  successful.  One  of  these 
patients  at  first  rejected  the  treatment  as  entirely 
inapplicable  to  him,  as  he  had  attempted  to  touch 
his  own  toe,  and  he  might  as  well  have  applied 
"  living   fire."      Nevertheless,   firm   pressure   and 

1  Gairdner,  On  Gout,  London,  1849,  p.  114. 

2  Op.  i'.it.,  p.  128. 

3  By  W.  Balfour,  M.D.  Vide  Edinburgh  Medical  and  Surgi- 
cal Journal,  Vol.  xii.,  p.  432.  And  none  of  us  have  forgotten 
the  old  gentleman  in  Sandford  and  3Ierton  who  was  cured  of  his 
gout  by  being  starved  and  locked  up  in  a  room  without  a  seat, 
the  floor  of  iron  being  gradually  heated  till  continual  move- 
ment became  a  necessity. 


ITS   CONCOMITANTS  AND   SEQUELS  173 

friction  entirely  removed  the  pain  in  ten  minutes, 
and  in  two  days  he  was  going  about  as  usual. 

Facts  such  as  these  are  worthy  of  the  most  care- 
ful consideration,  and  are  only  explicable  on  the 
theory  that  the  essential  lesion  in  an  attack  of  acute 
gout  is  the  formation  of  a  thrombosis  —  at  first 
probably  a  mere  stasis  —  in  such  a  situation  that 
an  infarction  is  a  necessary  consequence. 

In  the  gouty  —  that  is,  in  all  of  us  after  middle 
life,  more  or  less  —  thrombosis  is  always  a  possible 
occurrence,  and  it  plays  a  manifold  r61e,  the  impor- 
tance in  each  case  depending  on  the  position  of  the 
block. 

Thus  thrombosis  of  the  cortical  vessels  plays  a 
notable  part  in  progressive  softening  of  the  brain ; 
the  symptoms  varyinsf  according-  to  the    ^    ,   ,^ 

'J      ^  JO  o  Gouty  throtn- 

part   affected.      Thrombosis   or   stasis  bosis  pimjs  a 

in  the  motor  areas  is  often  limited  in  ^^«^^/^^^  ^^'^«- 

extent   and   temporary   in  character,  so   that  the 

resulting  paralysis  may  be  slight  and  evanescent, 

or  more  extensive,  more  complete,  and  permanent. 

The  same  may  be  said  of  Aphasia,  —  so  common 

in  the  gouty,  —  which  may  be  either  amnesic  or 

motor  in   character ;    and   either  incomplete    and 

temporary ;   complete   and  yet  tempo- 

,     .,  ,    ,  ,  Various 

rary ;  or  both  complete  and  permanent ;  symptoms 
the   last   rare   in  purely  gouty   cases,  from  cerebral 
Incomplete  attacks  of  a  paralytic  char- 


174  THE   SENILE  HEART 

acter  may  be  but  slight  and  pass  off  rapidly,  like 
the  twinges  about  the  heel  and  toes  which  quickly 
vanish.  Or  these  attacks  may  be  more  complete 
and  yet  quite  temporary  in  their  nature,  lasting 
just  about  the  usual  time  of  a  gouty  paroxysm  — 
from  two  to  three  weeks.  Single  attacks  of  corti- 
cal thrombosis  are  seldom  of  much  consequence, 
but  by  frequent  recurrence  they  may  ultimately 
produce  most  serious  results.  On  the  other  hand, 
central  thromboses  are  always  most  serious ;  some- 
times one  or  both  pupils  may  be  dilated ;  the 
breathing  may  be  deep  and  regular,  like  the  blow- 
ing of  a  bellows ;  and  death  may  occur  in  a  few 
hours,  preceded  by  a  considerable  rise  of  tempera- 
ture, coma,  or  muttering  delirium,  and  sometimes 
by  convulsions. 

Venous  thromboses  of  the  limbs  are  more  trouble- 
some than  dangerous,  in  those  who  are  otherwise 

healthy.      But   as   there  are  many  to 
Thromboses  of       -,  -\  i_  c  ^ 

limbs  whom   a   day  or  two    oi   recumbency 

always  means  the  blocking  of  one  or 

more  of  the  veins  of  the  extremities,  even  a  trifling 

catarrh  to  them  means  three  weeks  more  of  bed 

than  it  does  to  ordinary  people.     It  is  only  when 

such  a  patient  is  out  of   health    that   micro-cocci 

invade    these  clots,  which  then  break  down   and 

give  rise  to  showers  of  poisonous  emboli,  producing 

blood-poisoning  of  a  serious  character  with  scattered 


ITS   CONCOMITANTS  AND  SEQUELM         175 

septic  abscesses.  Nay,  it  sometimes  happens, 
especially  in  connection  with  a  dilated  senile 
heart,  that  perfectly  aseptic  thrombi  in  some  of 
the  smaller  veins  soften  and  break  down  into 
showers  of  minute  emboli,  with  no  other  result 
but  a  sudden  rise  of  temperature,  putting  on  the 
appearance  of  an  ague  of  irregular  type,  and  pro- 
longing convalescence  till  blood  and  heart  have 
both  improved  in  character.  Arterial  thromboses, 
which  are  often  the  result  of  embolism,  though 
sometimes  purely  autochthonous,  are  much  more 
serious,  and  are  apt  to  lead  to  senile  gangrene 
of  the  part  to  which  the  artery  affected  is  dis- 
tributed. 

Thrombosis  of   the  gastric  veins   after  middle 
life  is  followed  by  similar  results  to    „     -.,    ^ 

'J  Results «/ 

those  that  happen  at  an  earlier  age  ;  gastric 
there    is   pain    after   food,   ulceration,  ^  ^^^^  ^^^^' 
and  often  severe  hsematemesis.     Should  the  ulcer 
be  at  or  near  the  pylorus,  there  may  be  no  vomit- 
ing, only  dark-coloured  stools  —  melsena. 

It  is  not  alone,  or  chiefly,  the  altered  constitu- 
tion of   the  blood  that  gives  rise  to   ^, 

°  Cause  of  the 

the  formation  of  thrombi.     It  is  not  formation  of 
even  stagnation  of  the  circulation  that  *'^^^^^^' 
causes  the  blood  to  Qoagulate  in  the  veins.     These 
may  assist,  but   so    long   as   the    endothelium   is 
intact  and  performs   its    functions   normally,   the 


176  THE   SENILE  HEART 

blood  remains  fluid.^  The  conclusion  from  this 
is,  that  the  sluggish  venous  circulation  has  so 
impaired  the  vitality  of  the  endothelium  that 
thrombosis  is  at  once  precipitated,  more  especially 
in  certain  positions,  by  whatever  further  impairs 
the  constitution  of  the  blood  or  makes  its  move- 
ment more  sluggish. 

In  advanced  arterial  atherosis,    so   common   in 

gouty  patients,  the  endothelium  occa- 

Sourceof         sionallv  dies,  g-ets  washed  off,  and  so 

gouty  emboli.  »/  '  o 

permits  calcareous  spiculse  to  project 
naked  into  the  vascular  lumen ;  upon  which  the 
blood  coagulates.  In  arteries  of  a  moderate 
size  these  coagula  often  become  autochthonous 
thrombi  and  completely  block  the  artery.  In 
larger  vessels  the  coagula  projecting  into  the 
blood  current  occasionally  get  broken  off  and 
carried  as  emboli  into  smaller  arteries,  which  they 
either  block  completely,  or  they  may  block  it  in- 
completely, and  thus  form  a  nucleus  for  a  throm- 
bus, which  ultimately  completes  the  occlusion. 
In  this  way  embolism  of  the  brain  occasionally 
gives  rise  to  ingravescent  symptoms,  simulating 
those  caused  by  recurrent  hemorrhages. 

^Vide  Cohnheim,  op.  cit.,  Vol.  i.,  pp.  174  and  177;  also 
Bauingarten,  Die  Sogennante  Organisation  des  Thrombus, 
Leipzig,  1877  ;  also  Senftleben,  Vircliow's  Archiv,  Ixxvii.,  S. 
421 ;  and  Birk,  Das  Fibrinferment  im  lebenden  Organismus, 
Dorpat,  1880. 


ITS    CONCOMITANTS  AND   SEQUELM 


177 


Irregularity  of  nutrition  being  an  indication  of 
the    gouty   diathesis,   it   has    come    to    d-  7    7 

o        J  '  Rtdgea  and 

pass  that   longitudinally  ridged  (stri-  furroioed 
ated)  nails  have  been   regarded   as  a 
sign  of  gout  (Fig.  8),  and  so  they  doubtless  are. 
These    ridges   are   not   often   seen   before  middle 
life ;  they  sometimes   implicate  the  whole  surface 

of  the  nail;    at  other  times    there  is  

but  one  strongly  marked  ridge  from 
matrix  to  tip,  and  even  this  may  be 
irregularly  interrupted  by  narrow, 
transverse  furrows.  These  ridges  are 
a  sign  of  the  gouty  diathesis,  but 
have  no  connection  whatever  with  a 
gouty  paroxysm;  when  the  nails  are  '   '  , 

thin  they  often  split,  and  are  sometimes  very 
troublesome,  but  this  chiefly  in  advanced  life. 
Except  when  they  split  such  nails  are 
more  curious  than  important.  It  is 
otherwise  with  the  transverse  furrows 
occasionally  found  running  across  the 
nails  (Fig.  9).  These  are  best  marked 
on  the  thumb-nail,  which  is  the  thick- 
est, and  are  always  an  indication 
of  a  serious  illness  overlived.  Beau 
in  France,  and  Wilkins  here,  get  the  credit  of 
having  first  directed  professional  attention  to 
these   furrows;    but,   indeed,  their   presence    and 


Fig.  9. 


178  THE   SENILE  HEART 

signification  have  been  known  from  time  imme- 
morial, and  tliere  is  not  a  farrier  or  horse-cowper 
who  does  not  understand  the  importance  of  a 
transverse  furrow  on  the  hoof  of  a  horse,  or  who 
is  not  quite  up  to  the  advantage  of  new  shoes  and 
fresh  rasping  of  the  hoof  where  such  a  tell-tale 
exists.  As  the  thumb-nail  takes  six  months  to 
grow  from  matrix  to  tip,  the  position  on  the  nail 
indicates  with  tolerable  exactness  the  period 
elapsed  since  the  illness ;  it  is  but  seldom  that 
an  attack  of  gout  is  serious  enough  to  produce  such 
a  furrow. 

HeherderC s  knobs  are  very  distinctly  connected 

with  the  gouty  diathesis,  though  they 

Heberden's       ^j,^    ^^^   alwavs    connected   with   any 

knobs.  '^  ^ 

paroxysm.  Heberden  himself  says : 
"  What  are  those  little  hard  knobs,  about  the  size 
of  a  small  pea,  which  are  frequently  seen  upon 
the  fingers,  particularly  a  little  below  the  top 
near  the  joint?  They  have  no  connection  with 
gout,  being  found  in  persons  who  never  had  it ; 
they  continue  through  life  ;  and  being  hardly  ever 
attended  with  pain,  or  disposed  to  become  sores, 
are  rather  unsightly  than  inconvenient,  though 
they  must  be  some  little  hindrance  to  the  free 
use   of   the   fingers."  ^     These  knobs  are  common 

^  Commentaries  on  the  History  and  Cure   of  Diseases,  by 
William  Heberden,  London,  1803,  2d  ed.,  p.  148. 


ITS   CONCOMITANTS  AND   SEQUELS 


179 


enough,  and  there  are  few  physicians  of  any 
experience  who  have  not  had  an  opportunity  of 
watching    their    development.      They   sometimes 


Fig.  10.  —  At  a  two  of  Heberden's  knobs  are  seen  at  the  base  of 
the  distal  phalanx  of  the  forefinger;  over  the  head  of  its 
metacarpal  bone,  6,  there  is  a  tophaceous  mass. 


rapidly  grow  after  an  acute  affection  of  the 
fingers,  with  many  of  the  characteristics  of  a 
true  gouty  paroxysm;  at  other  times  they  are  of 
slow  and  gradual  growth,  accompanied  by  the 
ordinary  phenomena  of   gouty  dyspepsia,  but   at- 


180  THE   SENILE  HEART 

tended  by  no  more  remarkable  local  phenomena 
than  occasional  twinges  of  pain  about  the  joints, 
and  an  occasional  sense  of  fulness  and  stiffness  of 
the  fingers,  much  aggravated,  if  not  entirely  in- 
duced, by  gastric  disturbance.  For  diagnosis, 
however,  and  certainly  for  treatment,  we  have  to 
distinguish  between  Heberden  s  hnohs  and  Hay- 
garth's  nodosities}  The  knobs  are  extravascular 
deposits  in  the  neighbourhood  of  the  smaller 
joints,  chiefly  of  the  fingers,  but  they  may  be 
found  about  the  toes  also,  and  appear  as  gouty 
pearls  on  the  cartilage  of  the  ear.  They  begin 
like  small  ]3eas,  or  at  least  are  scarcely  noticed 
till  they  are  about  this  size,  but  they  sometimes 
attain  a  considerable"  size,  and  produce  great  and 
irregular  deformity  of  the  hands  or  other  parts 
affected ;  they  are  composed  of  urate  of  soda,  and 
are  popularly  known  as  chalkstones. 

The  nodosities^  on  the  other  hand,  are  associated 

with    rheumatoid    arthritis,    and    not 

Haygarth's       with  gout ;  they  are  really  "  exostotic 

nodosities.  ^ 

growths,  from  the  margins  of  the 
articular  surfaces,  as  well  as  from  the  periosteum 
and  bone  in  the  neighbourhood  of  the  diseased 
joints."  2      These    nodosities    lead    ultimately    to 

1  A  Clinical  History  of  Diseases,  part  2,  of  Nodosity  of  the 
Joints,  by  John  Haygarth,  Bath,  1805. 

2  A  Treatise  on  Rheumatic  Gout,  by  Robert  Adams,  M.D., 
London,  1873,  p.  16. 


ITS   CONCOMITANTS  AND   SEQUELM 


181 


anchylosis  of  the  joints  ;  and  the  deformity  of  the 
parts  affected,  when  the  hand  is  at  fault,  is  "in- 
variably associated  with  a  characteristic  adduction 
or  inclination  of  all  the  fingers  towards  the  ulnar 
side  of  the  hand.''^ 
The  knobs  are  due  to 
impurity  of  the  blood, 
the  nodosities  to  dis- 
ease of  the  bone. 
Gout  is  peculiar  to 
man  ;  rheumatoid  ar- 
thritis he  shares  with 
the  lower  animals, 
notably  with  the 
horse.  For  nearly  100 
years  the  impurity  in 
gouty  blood  has  been 
known  to  be  uric 
acid,  usually    present 

as  urate  of  soda.^    This  uric  acid  is  due  to  defective 
oxidation    of   the    effete    material   in    the  blood; 

1  Adams,  op.  ciY.,  p.  252. 

2  In  1797  Tennant  and  Wollaston  established  the  fact  that 
tophi  are  composed  of  urate  of  soda  ;  but  Charcot  rightly  says, 
"the  period  of  positive  knowledge  dates  from  Garrod's  re- 
searches in  1848,"  Clinical  Lectures  on  Senile  and  Chronic 
Diseases,  by  J.  M.  Charcot,  New  Sydenham  Society's  Trans- 
lation, 1881,  p.  127.  Vide  also  A  Treatise  on  Gout  and  Bheu- 
matic  Gout,  by  Alfred  Baring  Garrod,  M.D.,  London,  1876,  3d 
edition,  p.  49,  etc. 


Fig.  11.  —  Haygarth's  nodosities. 


182  THE   SENILE  HEART 

instead  of  urea  being  formed  and  excreted, 
the  lower  compound,  uric  acid,  is  formed  and 
retained.  At  certain  parts  of  the  body  —  about 
the  joints,  cartilages,  and  tendons  —  the  circu- 
lation, never  very  active,  gets  delayed  as  age 
advances.  The  blood-plasma,  flooding  the  tissue 
interspaces,  is  reabsorbed  but  slowly ;  the  urate 
of  soda,  never  very  soluble,  crystallizes  out  on 
some  slight  provocation,  and  gradually  grows  to 
gouty  pearls  on  the  ear,  to  Heberden's  knobs  on 
the  fingers,  and  to  so-called  tophaceous  deposits 
elsewhere.  The  synovial  oil  lubricating  the  joints 
and  tendons  is  less  perfectly  elaborated  than 
formerly ;  hence  the  gouty  stiffness  and  pain  on 
movement,  aggravated  by  a  certain  amount  of 
tension  in  the  tissue  interspaces,  which  is  always 
present,  and  is  worse  at  times.  Moreover,  the 
uric  acid,  or  urate  of  soda,  not  only  forms  knobs 
and  pearls  in  the  situations  specified,  but  now  and 
then  crystallizes  within  the  sheaths  of  the  tendons, 
notably  that  of  the  tendo  AchilUs,  giving  rise  to 
a  grating  sensation  on  movement,  which  is  often 
painful.  The  same  thing  may,  indeed,  be  found 
in  any  of  the  extravascular  spaces ;  for  senile 
re  mora  and  the  gouty  diathesis  modify  the  circu- 
lation throughout  the  whole  body,  as  well  as 
every  vital  process,  whether  it  be  normal  or  ab- 
normal. 


ITS    CONCOMITANTS  AND    SEQUELS  183 

There  is  one  other  symptom  of  gout  which 
deserves  special  mention,  and  that  is  a  "peculiar 
aura  or  rapid  twittering  motion  under  the  skin, 
as  it  were,  chiefly  in  the  back  and  limbs."  ^  This 
twitterinsf   of   the  superficial    muscles   ^    ,   ,   ., 

^  -■-  Gouty  twitter- 

is  limited  to  a  small  area;  it  comes  on  ingo/super- 
suddenly  and  is  of  short  duration;  in  -^^^^^ "^^^c^^-^- 
character  it  resembles  very  much  an  attack  of 
tremor  cordis,  but  being  quite  superficial,  it  is 
naturally  much  less  alarming.  Repeated  attacks 
of  this  twittering  sometimes  precede  an  attack  of 
gout,  but  this  symptom  is  often  found  where  only 
the  diathesis  prevails.  Its  causation  is  quite  as 
inexplicable  as  that  of  the  tremor  cordis  itself. 

The  infarction  theory  of  what  is  called  a  fit  of 
gout,  while  it  accords  with  and  explains  all  the 
obvious  facts  connected  with  an  attack,  still  leaves 
many  of  the  more  recondite  phenomena  unex- 
plained. For  example :  the  marked  hereditary 
character  of  true  gout,  and  the  remarkable  fact 
that  while  all  of  us  acquire  the  g-outy    „  ^ 

-••  o        J     oufferersfrom 

diathesis  as  age  advances,  not  a  tithe  Heberden's 
of   us   ever   suffer   from   a   paroxysm.    '^^^  ^  ^"''^  ^ 

■'-  '^  have  a  par- 

Yet  these   are    not    more  inexplicable   oxysmai 

than    the    fact   that   those  who  suffer  ''""'^^■• 

from  Heberden's  knobs  rarely  have  any  so-called  fit 

1  Vide  Contrihutions  to  Practical  il/e(^iane,  by  James  Begbie, 
M.D.,  Edinburgh,  1862,  p.  6. 


184  THE   SENILE  HEART 

of  gout  —  SO  rarely  that  Heberden  himself  says 
of  these  knobs,  "they  have  no  connection  with 
gout."  Yet  these  digitorum  nodi  are  certainly 
inseparably  connected  with  the  gouty  diathesis,  of 
which  they  are  signs  as  easily  recognized  and  as 
distinctive  as  enlarged  cervical  glands  and  irregu- 
lar cicatrices  are  of  struma. 

The  heredity  may  be  partly  of  structure ;  that 
as  yet  we  do  not  know.  It  certainly  is  of  function, 
^    ^    ,  and  the  function  is  that  of  the  stomach. 

Gouty  dys- 
pepsia is  often  We  know  this  to  be  inherited,  because 

m  en  e  .         long  before  there  can  be  any  question 

of  acquirement  we  find  the  gouty  dyspepsia  in  full 

swing ;  nay,  more,  in  quite  young  children  we  not 

only  find  the  gouty  intolerance  of  certain  articles 

of  food,  but  we  also  find  that  when  these  articles 

are  consumed  their  ingestion  is  followed  not  only 

by  all  the  usual  dyspeptic  symptoms,  but  also  by 

Gouti  d  s        stiffness    and  swelling   of   the    digits. 

pepsiamay       Gouty  dyspcpsia  means  a  feeble   and 

be  curable.  •  £      i    t        j.-  •        •  i 

imperiect  digestion ;  occurring  m  early 
life,  it  must  be  largely  a  matter  of  inheritance, 
though  it  may  be  aggravated  by  injudicious  feed- 
ing in  infancy,  and  possibly  enough  it  may  even 
be  to  some  extent  acquired  in  this  way.  I  need  not 
say  that  as  care  and  diet  can  do  much  to  relieve 
gouty  dyspepsia  at  any  age,  so,  at  an  early  age,  when 
as  yet  unaccompanied  by  any  structural  alterations. 


ITS    CONCOMITANTS  AND   SEQUEI^  185 

it  may  not  only  be  greatly  relieved,  but  may  even 
be  cured. 

Gouty  dyspepsia  in  advanced  life  can  always 
be  greatly  relieved ;  but  as  the  cause  is  structural 
and  permanent,  watchful  care  is  always  a  lifelong 
necessity.  The  essential  element  of  gouty  dys- 
pepsia is  feebleness  of  digestion.  The  gastric  juice, 
like  all  the  other  secretions,  is  secreted  at  a  low 
pressure,  it  is  poor  in  quality,  and  defective  in 
quantity ;  hence  imperfect  digestion.  Some  of  the 
food  escapes  the  action  of  the  gastric  juice,  and 
instead  of  being  formed  into  healthy  chyme  it 
breaks  up,  under  the  influence  of  heat  and  moist- 
ure, into  various  compounds  productive  of  dis- 
comfort in  the  stomach  and  of  sundry  ill  effects 
when  absorbed  into  the  blood.  The  food  may 
undergo  acid  fermentation,  acetic  and  butyric 
acids  being  set  free,  which  irritate  the  gastric 
mucous  membrane,  inducing  a  catarrhal  condi- 
tion with  excess  of  mucus,  which  hampers  the 
primary  digestion  in  the  stomach,  and  by  extend- 
ing along  the  duodenum  and  bile  ducts  may  in- 
terfere with  the  free  passage  of  the  bile  and 
thus  impede  secondary  digestion.  A  sense  of 
fulness  and  oppression,  with  pain  and  acidity  or 
more  often  flatulence  after  meals,  indicate  that 
digestion  is  being  interfered  with,  and  result  in 
the  fluttering  and  irregular  heart,  so  usual  a  con- 


186  THE   SENILE  HEART 

comitant  of  gouty  dyspepsia.  The  irritated  and 
congested  condition  of  the  gastric  mucous  mem- 
brane is  the  great  cause  of  the  gouty  Bulimia^ 
which  is  not  only  the  result,  but  also  a  very  effi- 
cient cause,  of  much  of  this  dyspepsia.  Then  we 
have  the  disturbed  sleep  —  the  gouty  insomnia, 
the  irregular  bowels,  and  the  lateritious  sediment 
in  the  urine,  which  together  make  up  those  ex- 
ternal indications  that  reveal  to  the  most  unob- 
servant the  existence  of  the  gouty  diathesis. 


CHAPTER   VIII 

THE   SENILE   HEART,    ITS    CONCOMITANTS    AND 
SEQUELS.      GLYCOSURIA,  GOUTY  KIDNEYS 

There  are  several  important  organs  in  the 
body  which  are  very  gravely  affected  by  the 
changes  in  the  circulation  due  to  advancing  age, 
notably  the  liver  and  the  kidneys.  In  their  turn, 
the  alterations  in  the  structure  and  functions  of 
these  organs,  thereby  induced,  very  materially 
modify  all  the  organic  processes  during  the  future 
progress  of  life. 

Oliver  Wendell  Holmes  says  that  the  most  satis- 
factory and  comforting  opinion  that  can  be  given 
to  a  patient,  is  to  tell  him  that  he  suffers  from  con- 
gestion of  the  portal  system.  And  there  may  be 
truth  in  this  view ;  but  to  tell  him  that  he  suffers 
from  too  much   or  too  little  bile,   or 

Bile  hut  the 

from  biliousness  generally,  expressions  drainage  of  a 

never  out  of  the  mouth  of  a  valetudi-  ^"''S'^  mann- 
er -,-  ^  factorij. 
narian,  is  to  make  use  of  words  without 

meaning,  now  that  we  know  that  bile  is  only  the 

187 


188  THE  SENILE  HEART 

drainage  of  a  large  manufactory,  and  is  itself 
apparently  of  but  little  use  in  the  animal  economy .^ 
Indeed,  the  discomfort  which  we  know  to  accom- 
pany the  absence  of  bile  from  the  stools  must  now- 
adays be  looked  upon  as  entirely  due  to  the  cessa- 
tion of  the  manufacture,  and  not  to  the  absence  of 
the  product  from  the  intestinal  contents.  The 
amount  of  bile  secreted  in  a  day  amounts  to  some- 
what over  a  pint  (638  ccm.),^  and  though  this  is 
nearly  all  reabsorbed,  and  the  movement  of  the  bile 
and  pancreatic  secretion  may  thus  be  regarded  as 
the  analogue  of  the  abdominal  circulation  of  the 
Gasteropods,   yet    as    these    secretions    are   most 

1 "  From  June,  1890,  to  the  present  date,  March,  1892,  every 
drop  of  bile  has  been  poured  out  on  the  surface,  and  there  has 
been  no  evidence  that  any  has  entered  the  duodenum.  Never- 
theless, her  health  and  strength  have  steadily  imi)roved.  .  .  .  She 
is  fat,  and  must  weigh  eleven  or  twelve  stones.  She  tells  me 
that  since  her  return  home  she  has  never  had  a  day's  illness,  that 
she  is  up  every  morning  at  her  household  duties  at  five  o'clock. 
She  states  that  her  appetite  is  very  good,  and  that  she  can  eat 
all  kinds  of  food,  even  the  most  fatty,  with  perfect  impunity. 
Her  bowels  move  once  a  day  without  medicine.  It  would  be 
impossible  to  adduce  stronger  evidence  against  the  view  that 
bile  plays  any  important  part  in  the  digestive  process."  Vide 
"  Further  Observations  on  the  Composition  and  Flow  of  the  Bile 
in  Man."  By  D.  Noel  Paton,  M.D.,  Laboratory  Beports  of  the 
Boyal  College  of  Physicians,  Edinburgh,  1892,  Vol.  iv.,  p.  44. 

2  Vide  "  (Jn  the  Composition,  Flow,  and  Physiological  Action 
of  the  Bile  in  Man."  By  D.  Noel  Paton,  M.D.,  F.R.C.P.  Ed., 
and  John  M,  Balfour,  M.B.,  CM.,  Laboratory  Beports  of  the 
Boyal  College  of  Physicians,  Edinburgh,  1891,  Vol.  iii.,  p.  193. 


ITS   CONCOMITANTS  AND   SEQUELS  189 

copious  just  after  the  ingestion  of  a  meal,  they 
must  to  some  extent  relieve  the  vascular  turgor 
always  greatest  at  that  time.  An  active  liver  is  a 
pTeat  relief  in  cases  of  weak,  dilated   „ 

o  '  Free  secretion 

hearts,  and  the  abdominal  circulation  of  bUe  relieves 
just  referred  to  affords  a  reasonable  ^^««^^^«^^- 
explanation  of  this.  In  weakly  subjects,  to  obtain 
this  relief  it  is  enough  to  employ  an  appropriate 
cholagogue  in  a  dose  sufficient  to  act  upon  the 
liver  alone,  without  purging. 

The  two  great  manufactures  of  the  liver  are 
urea  and  glucose.  Urea  is  the  chief  ultimate 
product  of  the  oxidation  of  nitrogenous  bodies, 
and  when  these  are  in  excess,  or  when  there  is 
a  hypo-oxygenated  venosity  of  the  blood,  as  hap- 
pens in  all  more  or  less  after  middle  life,  but 
especially  when  the  heart  gets  dilated,  then  we 
have  the  less  oxidized  product  —  uric  acid  — 
formed,  and  its  neutral  salts  saturating  the  system 
—  the  gouty  diathesis  in  full  swing.  Under  these 
conditions  there  is  always  congestion,  often  enlarge- 
ment of  the  liver.  There  is  never  any  difficulty  in 
detecting  in  the  urine  the  deficiency  of  urea  and 
the  excess  of  uric  acid  and  its  salts ;  but  there  is 
more,  for  in  all  cases  of  congested  and  gouty  liver 
we  get  in  the  urine,  with  Moore's  test  (liquor 
potassse),  a  yellow  colour  which  deepens  with  the 
congestion,  until  in  many  cases  we   have  gouty 


190  THE   SENILE  HEART 

glycosuria  fully  developed.  There  seems  to  be  a 
regular  gradation  from  the  faintest  tinge  of  colour 
to  unmistakable  sugar,  detectable  by  every  known 
test,  so  that  it  seems  a  little  difficult  and  somewhat 
invidious,  to  say  up  to  this  point  there  has  been  no 
sugar,  now  there  is.  Mucin  {Nucleoalhumiri)  in 
the  urine  strikes  a  yellow  colour  when  the  fluid  is 
boiled  with  liquor  jDotassae,^  while  uric  ^  and  gly- 
curonic^  acids,  kreatin  and  kreatinin,^  all  decom- 
pose the  copper  in  Trommer's  and  in  Fehling's 
tests  when  boiled  with  them ;  and  as  these  are  all 
present  in  gouty  urines,  a  yellow  colour  is  con- 
tinually to  be  found  in  such  urines  when  these 
tests  are  employed.  The  fermentation  test  itself 
may  be  fallacious,  because  other  matters  besides 
sugar  are  decomposed  under  the  influence  of 
ferment.^  So  long  as  the  sugar  is  in  a  minute 
quantity,  it  seems  scarcely  possible  to  say  whether 
it  is  actually  present  or  not ;  when  it  is  found  in  a 
larger  amount,  the  difficulty  lies  in  determining 
whether  we  have  to  do  with  a  true  diabetes  or 

1 V.  Jaksch,    Klinische    Diagnostik,  3e  Auflage,   Wien   u. 
Leipzig,  1892,  S.  327. 

2  V.  Jaksch,  op.  cit. ,  S.  328. 

3  Aslidown,  Proceedings  of  the  Boyal  Society  of  Edinburgh^ 
Vol.  xvii.,  p.  58. 

^  V.  Jaksch,  loc.  cit. 

^  Thudichum,  Pathology  of  the  Urine,  London,  1877,  p.  429  ; 
V.  Jaksch,  op.  cit.,  S.  329. 


ITS   CONCOMITANTS  AND   SEQUELS  191 

merely  with  a  gouty  glycosuria.  To  determine 
this,  we  have  to  fall  back  upon  other  subsidiary 
symptoms. 

Gouty  glycosuria  has  a  knack  of  turning  up  at 
odd  times  and  in  an  unexpected  man-  „  ^  . 
ner.  More  than  a  dozen  years  ago  an  gouty 
elderly  gentleman  presented  himself  ^  ^^°^^'  ^^• 
to  me  with  a  dilated  heart,  an  enlarged  liver,  very 
considerable  general  dropsy,  marked  oedema  of  the 
lungs,  and  about  one-third  of  albumin  in  his  urine, 
which  was  scanty.  He  was  puffy  all  over  from 
general  oedema,  but  seemed  also  to  be  well 
nourished,  and  had  no  particular  thirst,  nor  any 
ravenous  appetite ;  just  about  the  kind  of  case  in 
which  one  would  least  think  of  looking  for  sugar 
in  the  urine,  yet,  on  examination,  over  five  per 
cent  of  glucose  was  detected.  The  coexistence 
of  albumin  with  glucose  in  the  urine  is  not 
usually  regarded  as  favourable  to  the  patient,  but 
the  prognosis  depends,  not  upon  the  coexistence 
of  these  substances,  but  upon  the  probable  cause 
of  the  presence  of  them  both.  In  this  case  the 
dilated  heart  was  the  evident  cause ;  venous  con- 
gestion of  the  kidneys  leading  to  albuminuria, 
and  venous  congestion  of  the  liver  to  glycosuria. 
A  dilated  heart  is  an  improvable,  if  not  always  a 
curable,  organ,  even  though  the  dilatation  is  senile 
in  character,  and  the  old  gentleman  made  a  most 


192  THE   SENILE  HEART 

excellent  recovery.  His  heart  improved  in  a  re- 
markable manner,  the  dropsy  passed  entirely 
away,  and  the  glycosuria  disappeared.  He  lived 
for  several  years,  and  was  able  to  carry  on  his 
business  comfortably.  He  had  to  do  a  good  deal 
of  travelling  and  occasionally  caught  cold,  and 
this  invariably  broke  down  his  cardiac  compen- 
sation and  brought  about  a  return  of  all  his 
symptoms,  but  never  to  so  considerable  extent 
as  at  first.  I  saw  him  occasionally  at  long 
intervals  for  these  relapses,  but  the  illness  was 
always  taken  in  time,  and  there  was  never  more 
than  a  trace  of  either  sugar  or  albumin  to  be 
found.  At  first  he  was  dieted,  but  not  strictly, 
and  more  for  the  sake  of  his  heart  than  of  his 
glycosuria ;  there  was  never  any  subsequent  need 
for  this.  He  died  some  years  ago  from  pneu- 
monia. 

Another  old  gentleman,  sixty-eight  years  of  age, 
on  his  way  to  Vichy,  whither  he  had  been  sent  by 
two  physicians  on  account  of  gouty  symptoms, 
was  picked  up  by  a  London  specialist,  who  de- 
tected a  considerable  quantity  of  sugar  in  his 
urine.  This  gentleman  was  told  that  his  disease 
had  been  misunderstood,  that  he  had  diabetes  and 
not  gout,  that  he  need  not  go  to  Vichy,  but  should 
return  home  and  follow  the  regimen  prescribed, 
which,  if   it   did   not   cure   him,  would  certainly 


ITS   CONCOMITANTS  AND   SEQUELS  193 

alleviate  his  symptoms.  Unfortunately,  the 
patient's  former  advisers  had  not  previously 
tested  his  urine  for  sugar,  and  the  scene  on  the 
patient's  return  must  be  left  to  the  imagination. 
By  and  by  this  patient  fell  into  my  hands.  I 
ascertained  that  he  was  well  nourished,  and  had 
not  been  losing  flesh ;  that  he  had  hard,  tortuous 
arteries,  and  a  failing  heart;  a  sluggish  liver,  not 
markedly  enlarged ;  and  that  his  urine  was  loaded 
with  uric  acid,  which  crystallized  out  as  a  copious 
sediment ;  that  the  specific  gravity  of  the  urine 
was  1028,  and  that  it  contained  about  five  per 
cent  of  sugar.  I  had  no  difficulty  in  telling  the 
patient  that  his  former  attendants  had  undoubt- 
edly erred  in  not  ascertaining  the  presence  or 
absence  of  sugar,  but  that  otherwise  their  opinion 
was  entirely  correct,  and  the  presence  of  glyco- 
suria only  confirmed  their  view,  and  was  of  no 
material  importance  in  the  case.  Naturally  this 
patient  had  to  be  dieted  for  gout,  but  not  for 
diabetes,  which  did  not  exist.  In  no  long  time 
the  arterial  degeneration  began  to  affect  the 
brain ;  the  mind,  hitherto  strong  and  dogmatic, 
began  to  waver  and  have  fancies  which  the  patient 
could  not  distinguish  from  realities,  though  aware 
there  was  a  difference  which  he  could  neither  de- 
scribe nor  account  for.  By  and  by  there  was 
a   marked    declension    of   bodily  vigour,  but   the 


194  THE  SENILE  HEART 

patient  kept  well  nourished  to  the  last.  He  died 
of  cerebral  hemorrhage  several  years  subsequent 
to  the  episode  referred  to,  the  glycosuria  having, 
to  my  knowledge,  persisted  up  to  a  few  weeks 
before  his  death. 

Again,  about  fourteen  years  ago  a  publican 
chanced  to  be  in  a  railway  accident.  Some  months 
subsequently  he  was  found  to  be  passing  sugar, 
and  his  ailment  was  dubbed  traumatic  diabetes 
by  his  medical  advisers.  He  was  also  supposed 
to  be  suffering  from  several  obscure  nervous  ail- 
ments due  to  spinal  concussion.  In  the  course  of 
his  action  against  the  railway  company,  his  dia- 
betes was  represented  as  of  a  most  serious  charac- 
ter, traumatic  in  origin  and  due  to  the  accident; 
six  years  were  assigned  as  the  utmost  limit  of 
his  life.  I  found  this  patient  to  have  a  dilated 
heart  and  a  large  liver ;  also  that,  like  many  other 
publicans,  he  was  a  free  liver.  He  was  fat  and 
well  nourished;  and  in  spite  of  having  passed  a 
considerable  quantity  of  sugar  daily  for  many 
months,  and  probably  for  years,  there  was  not 
only  no  emaciation,  but  also  neither  thirst  nor 
ravenous  appetite.  For  these  and  other  reasons 
I  had  no  difficulty  in  declaring  that  this  patient 
did  not  suffer  from  diabetes,  either  idiopathic  or 
traumatic ;  that  he  had  only  gouty  glycosuria, 
which  in  itself  would  not  shorten  his    days,  and 


ITS   CONCOMITANTS  AND   SEQUELS  195 

which  had  probably  existed  for  several  years 
before  the  date  of  the  accident.  This  patient 
still  survives  to  attest  the  correctness  of  my 
opinion,  in  excellent  health,  passing  as  much 
sugar  as  ever,  and  in  the  full  enjoyment  of 
the  exceptionally  heavy  damages  which  the  jury 
awarded  him. 

These  three  cases  may  serve  to  give  an  idea  of 
the  various  circumstances  in  which  gouty  glyco- 
suria may  turn  up,  and  in  which  it  is  of  conse- 
quence to  remember  that  glycosuria  is  not  diabetes, 
that  the  mere  presence  of  sugar  in  the  urine  is 
not  a  disease,  that  it  is  not  of  uncommon  occur- 
rence in  gouty  people,  and  that  it  is  specially  apt 
to  be  found  when  the  heart  is  dilated  and  the 
liver  enlarged.  In  these  cases  of  glycosuria,  even 
when  the  quantity  of  sugar  passed  is  considerable 
(as  much  as  five  per  cent),  there  is  no  emaciation, 
and  there  is  a  possibility  of  a  cure.  Strict  dieting 
is  quite  unnecessary  in  such  cases,  as  even  though 
the  sugar  may  never  disappear  from  the  urine,  its 
persistence  is  not  accompanied  by  wasting  of  the 
body  or  by  any  other  serious  symptom.  The  sugar 
seems  to  be  excreted  simply  because  it  is  in  excess 
of  the  requirements  of  the  system,  either  as  a 
result  of  the  superfluity  of  nutriment  ingested,  or 
of  a  diminished  consumption  from  deficient  mus- 
cular  exertion ;   probably   both   of   these    circum- 


196  THE   SENILE  HEART 

stances  have  each  a  share  in  bringing  about  the 
ultimate  result.  Gouty  glycosuria  as  a  rule  is 
easily  controlled  by  regulation  of  the  diet,  and 
many  reputed  cures  of  diabetes  have  probably  been 
cases  of  this  character. 

The  connection  between  the  kidneys  and  the 
PosBihiiity  of  l^eart  has  for  long  been  a  subject  of 
a  reciprocal      great  interest  to  the  profession.     We 

action  he-  i  j^i     ■     i  i^   r   '^  •  •        i 

tween  the  Ki^ow  that  heart  lailure  gives  rise  to 
kidneys  and     albuminuria  through  the  intermediacy 

the  heart.  /.  .  .  r      l^  ^  •  ^  ^      , 

01  congestion  or  the  kidneys,  but 
whether  disease  of  the  kidneys  is  of  equal  im- 
portance in  influencing  the  condition  of  the  heart 
has  long  been  a  subject  of  controversy,  and  the 
literature  bearing  upon  this  problem  is  both  volu- 
minous and  important. 

There  is  no  form  of  kidney  affection,  any  more 
than  there  is  any  other  kind  of  disease,  which 
is  not  occasionally  associated  with  disease  of  the 
heart  in  some  one  or  other  of  its  forms,  and  that 
either  accidentally  or  for  sundry  efficient  reasons. 
But  there  is  one  form  of  heart  affection  so  invaria- 
bly associated  with  one  particular  form  of  kidney 
disease  that,  for  sixty  years  past,  the  relationship 
has  been  assumed  to  be  one  of  cause  and  effect, 
while  professional  opinion  has  not  yet  decided 
which  of  the  two  oug^ht  to  be  reo-arded  as  the 
cause  and  which  as  the  effect. 


ITS   CONCOMITANTS  AND   SEQUELS  197 

The  almost  invariable  coincidence  of  the  red 
contracting  kidney  with  hypertrophy  of  the  left 
ventricle  of  the  heart  did  not  escape 

The  cirrhotic 

the    accurate    observation    ot    Bright,   udney  always 
He  sought  an  explanation  of  this  in  (associated 

.   .  with  hyper- 

the  supposition  that  "  the  altered  qual-  trophy  of  the 
ity  of  the  blood  so  affects  the  minute   ^^f^  ventricle 

.  .  T        of  the  heart. 

and  capillary  circulation  as  to  render 

greater   action    [of   the    left  ventricle]   necessary 

to   force    the   blood  througfh   the   dis-    ^  .  ,,, 

o  Bright  s 

tant  subdivisions  of  the  vascular  sys-  expAanation 

1         ?;  1  of  this. 

tern.    ^  -^ 

But  Bright  overlooked  the  fact  that  in  other 
renal  diseases  where  the  blood  is  also  notoriously 
impure,  from  the  admixture  of  urinary 
constituents,  no   such  hypertrophy  of  J^^'^^^^f' 

^  ■'--'-     "^  ficzency. 

the  left  ventricle  occurs.     Bright  also 

failed  to  show  that  the  blood  is  always  impure 

before  the  cardiac  hypertrophy  commences. 

Traube,  on   the   other  hand,  pointed  out  that 
hypertrophy   of   the    left  ventricle   is 
not  the  result  of  blood  impurity,  be-   ^^'^'^^^'^ 

^         ^  '  view. 

cause   it   does    not   accompany   every 
form  of  diffuse  renal  disease,  but  is   only  found 
in  connection  with  the  cirrhotic  kidney.     And  he 
propounded  the  doctrine  that  this  hypertrophy  is 
the  result  of  the  call  for  increased  exertion  made 

1  Guy's  Hospital  Beports,  Vol.  i.,  p.  396. 


198  THE   SENILE  HEART 

upon  the  heart  by  the  rise  of  the  intra-arterial 
blood  pressure,  a  rise  which  he  believed  to  be  due 
to  the  obliteration  of  so  many  arterial  branches 
within  the  kidneys  with  the  Malpighian  tufts 
attached  to  them.^  But  Traube  overlooked  the 
fact  that  cardiac  hypertrophy  is  not  found  asso- 
ciated with  every  form  of  contracting  kidney, 
notwithstanding  a  similar  limitation  of  the  intra- 
renal  capillary  area,  but  is  only  found  in  connec- 
tion with  the  red,  granular,  cirrhotic  kidney. 
We  know,  also,  that  destruction  of  one  or  both 
kidneys,  congenital  or  acquired  (cys- 
.  ^^ ^  .    ,        tic  kidneys,  hydronephrosis,  extensive 

insufficient.  j    ^      j  r 

embolic  cicatrices,  etc.),  extirpation  of 
one  kidney,  amputation  of  one  or  more  limbs,  are 
all  of  them  accompanied  by  a  much  greater  limi- 
tation of  the  capillary  area  than  ever  happens  in 
any  case  of  cirrhotic  kidney,  and  they  are  never- 
theless entirely  without  influence  in  inducing 
any  intra-arterial  rise  of  blood  pressure.  Traube 
also  neglected  to  make  sure  that  the  heart  was  not 
already  affected  before  the  commencement  of  the 
kidney  disease. 

According  to  Sir  George  Johnson :   "  The  pri- 
mary and  essential  structural  changes  consist  in  a 
desquamation,  disintegration,  and  removal  of  the 
renal  gland-cells,   .  .  .  changes  in  the  glandular 
1  Gesammelte  Beitrlige,  Band  ii.,  S.  290,  etc. 


ITS   CONCOMITANTS  AND   SEQUEIM  199 

epithelium,  the  result  of  a  modified  cell-nutrition, 
consequent  on  a  morbid  condition  of 
blood  associated  with  gout,"  various  ^qj^^^IqI^^ 
forms  of  dyspepsia,  etc.^     Johnson  be-  pathology  of 

T  J.X.    J-  J.1,     1  •  1  1^    •  1  ihe  cirrhotic 

lieves  that  the  kidneys,  being  no  longer  , . , 
able  fully  to  discharge  their  function, 
owing  to  destruction  of  their  tissue,  the  renal 
arterioles  take  on  a  stop-cock  action  to  cut  off 
that  excess  of  blood  which  is  no  longer  required, 
because  it  can  no  longer  be  depurated.  This  per- 
sistent action  of  the  arterioles  he  naturally  believes 
to  result  in  hypertrophy  of  their  muscular  coat. 
In  consequence  of  the  failure  of  the  kidneys  to 
discharge  their  function  the  blood  is  necessarily 
impure,  and  more  or  less  unfit  for  the  perfect 
metabolism  of  the  tissue.  To  cut  off  this  unsuit- 
able nutriment  from  the  tissues,  Johnson  sup- 
poses that  the  systemic  arterioles  also  take  on 
a  stop-cock  action,  while  for  the  very  necessary 
purpose  of  maintaining  the  circulation  at  its  norm, 
in  spite  of  this  increased  peripheral  obstruction 
and  consequent  rise  of  blood  pressure,  the  left  ven- 
tricle is  forced  to  make  extra  exertion,  and  con- 
sequently hypertrophies.^  But  Johnson's  theory 
postulates   too   many   problems    as   yet   unsolved 

1  Jolinson,  Medical  Lectures  and  Essays,  London,  1887,  p. 
700,  etc. 

2  Johnson,  op.  cit. ,  p.  705. 


200  THE   SENILE  HEART 

and  unaccepted  by  modern  physiology  to  be  of 
75  unsatisfac-  any  pathological  value.  This  theory 
torr/  because     -^   ^^^^        -^^    incompatible   with   any 

based  upon  x  c  j 

views  unac-  relative  cardiac  hypertrophy  preceding 
cepte     y         ^^   kidney  disease.      Johnson   conse- 

niodern  '^ 

physiology.       quently  ignores  this. 

Next  to  Traube's,  the  theoretic  pathology  of  the 
cirrhotic  kidney  which  has  most  impressed  the  pro- 
fession,  has   been   that   of    Gull   and 
Gull  and  Sutton.     They  deny  any  direct  causal 

Sutton  s  pa-  '^  j         j 

thoiogy  of  the    Connection  between  renal  cirrhosis  and 

cirrhotic  hypertrophy  of  the  left  ventricle  of  the 

kidney.  ^  ^  ^   '^ 

heart.  They  hold  that  these  two  con- 
ditions are  the  result  of  one  general  affection  of 
the  arterial  system,  to  which  they  have  given  the 
name  of  arterio-capillary  fibrosis,  or  hyalin-fibroid 
disease  of  the  arteries.^  Gull  ahd  Sutton  acknowl- 
edge two  forms  of  contracting  kidney.  One  of 
these  occurs  as  a  local  disease,  and  in  most  cases, 
if  not  in  all,  is  the  product  of  an  acute  nephritis. 
This  form  may  occur  at  any  age,  and  is  unattended 
by  any  change  in  the  heart,  and  by  very  little,  if 
any,  recognizable  change  in  any  of  the  other  organs 
in  the  body.  The  other  form  of  contracting  kidney 
is  not  common  before  forty  years  of  age,  is  often 
associated  with  hypertrophy  of  the  heart,  diseased 
vessels,  and  more  or  less  widespread  changes  in 

^  Medico- Chirurgical  Transactions^  1872,  Vol.  Iv.,  p.  273,  etc. 


ITS   CONCOMITANTS  AND   SEQUELS         201 

other  organs.^  In  these  cases  the  kidney  affection 
is  not  always  the  primary  disease,  nor  can  the  other 
organic  failures  be  attributed  to  the  kidney  disease. 
According  to  Gull  and  Sutton,  the  arterio-capillary 
fibrosis  primarily  affects  the  vascular  system  —  to 
wit,  the  arterioles;  and  it  invades  the  other  organs 
—  the  heart,  the  kidneys,  the  lungs,  the  brain,  the 
spinal  cord,  etc.,  not  simultaneously,  nor  in  any 
sequential  manner,  but  as  it  were  casually,  as  part 
of  a  widespread  cachexia  which  has  its  basis  in  the 
vascular  system. 

But  a  widespread  arterial  degeneration,  rarely 
found  before  the  age  of  forty,  has  a  suspiciously 
close   resemblance   to  senile   degener- 
ation, and  the  results  described  as  fol-   y"^^^" 

thology  closely 
lowing  hyalin-fibroid  alteration  of  the   resembles,  in 

arterial  coats  are  precisely  similar  to  ^^«  ^"'^^o^?/ «^f^ 

■'-  *'  results,  senile 

those  originating  in  failure  of  arterial  degeneration 
elasticity.     The  heart  found  connected  ""^^^^  ^'*'^'" 

•^  nary  type. 

with  the  cirrhotic  kidney  is  always  in 
the  state  of  dilated  hypertrophy  usual  in  the  senile 
heart,  varying  in  degree  in  each  individual  case. 
Primarily  this  affects  the  left  ventricle,   ^,    ^ 

'^  '    The  heart  is 

but  it  is  not  restricted  to  it,  and  it  will  simply  a  senile 

be  found  affecting  both  ventricles,  more     ^^^^' 

or  less,  in  every  case,  and  not  merely  in  a  matter 

^Lectures  on  Pathology,  by  the  late  H.  G.  Sutton,  M.B., 
r.R.CP.,  London,  1891,  p.  431,  etc. 


202  THE   SENILE  HEART 

of  70  per  cent,  as  Buhl  would  have  it.^  This 
dilated  hypertrophy  of  the  heart  is  also  always 
associated  with  loss  of  elasticity  and  dilatation  of 
the  large  arteries  —  the  aorta  above  the  valves 
averaging  in  circumference  7.6  cm.  as  against  a 
normal  of  6.3  cm.^  Lastly,  this  dilated  hyper- 
trophy of  the  heart,  as  Bamberger,^  Schroetter,* 
and  others  tell  us,  always  precedes  the  kidney 
affection.  Among  the  scores  of  senile  hearts 
which  have  come  under  my  own  observation,  there 
have  been  many  with  cirrhotic  kidneys.  In 
those  that  proved  fatal  at  a  comparatively  early 
stage  the  heart  affection  has  always  seemed  to 
be  in  advance  of  the  kidney,  and  in  some  few  I 
have  satisfied  myself  that  this  was  actually  the 
case. 

The  cirrhotic  kidney,  as  every  one  knows,  may 
be  contracted  to  one-half  or  one-third  of  its  natural 
size;  it  is  shrivelled,  its  capsule  thickened  and 
opaque,  and  its  surface  granular.  On  section  the 
shrivelling  is  found  to  be  chiefly  at  the  expense  of 
the  cortical  portion,  and  the  cut  surface  is  flecked 

1  Buhl,  Blittheilungen  aus  dem  pathologischen  Institut  zu 
Muncheth  Stuttgart,  1878,  S.  64,  etc. 

2  This  fact  is  noted  by  many  authors.  These  figures  are 
taken  from  Ewald,  in  Virchow''s  Archiv.,  Bd.  Ixxi.,  S.  477. 

8  Lehrhuch  der  Krankheiten  des  Herzens,  Wein,  1857,  S.  328. 
*  Ziemssen'' s   Cyclopedia   of  Practical   Medicine^   Vol.   vi., 
p.  192. 


ITS   CONCOMITANTS  AND   SEQUELS         203 

with  streaks  and  specks  of  white  from  salts  of  uric 
acid  scattered  throughout  the  cortex  and  between 
the  tubules.  The  presence  of  these  salts  in  the 
stroma  of  the  kidney  has  the  same  significance  as 
elsewhere  (vide  antea^  p.  168).  It  indicates  a  rem- 
ora  of  the  circulation  sufficient  to  permit  those  com- 
paratively insoluble  salts  to  crystallize 

T7i6  ciwhotic 

out  of  the  lymph  which  floods  the  j^if^^Qy « 
tissue  interspaces.  This  remora  is  due  ^^^^^  9^^*y 
to  venous  congestion,  the  result  of 
commencing  failure  of  the  central  organ  of  the 
circulation,  and  is  accompanied  by  all  the  usual 
consequences  of  venous  hypersemia.  One  of  the 
consequences  of  venous  congestion  of  any  organ, 
laid  down  by  Sir  William  Jenner  as  a  pathological 
law,  is  that  the  structure  of  any  organ  so  con- 
gested becomes  hard,  tough  in  texture,  and  in- 
creased in  bulk  by  an  exudation  of  lymph,  which 
is  ultimately  converted  into  fibrous  tissue.  By 
and  by  this  new-formed  tissue  contracts,  and  if 
the  organ  be  a  kidney,  its  surface  becomes  uneven 
and  granular,  and  cysts  are  developed.^  The 
structure  of  the  kidney  easily  lends  itself  to  these 
changes.     The  cysts  are  readily  accounted  for  by 

1  Vide  Medico- Chirurgical  Transactions,  Vol.  xliii.,  p.  199  ; 
and  Dickinson's  Diseases  of  the  Kidney,  etc.,  Part  ii.,  p.  385,  etc. 
Vide,  also,  Schmaus  and  Horn,  Ueber  den  Ausgang  der  cyanoti- 
schen  Induration  der  Niere  in  Granularatrophie,  Wiesbaden, 
1893. 


204  THE   SENILE  HEART 

the  blocking  off  of  some  part  of  a  tubule,  either  at 
its  commencement  in  a  Malpighian  capsule,  or  in 
some  other  part  of  its  course ;  while  the  pyramids 
of  Ferrein,  even  in  health,  present  a  somewhat 
granular  appearance  on  the  surface  of  the  kidney, 
and  when  the  septa  between  them  are  hyper- 
trophic d  and  contracted,  they  must  largely  con- 
tribute to  the  well-known  granular  aspect  of  the 
cirrhotic  kidney. 

Indeed,  when  we  consider  the  contractions  and 
deformities  that  disfigure  the  comparatively  rigid 
tissues  of  the  extremities  of  those  suffering  from 
the  influence  of  the  gouty  diathesis,  from  the 
vascular  changes  upon  which  this  diathesis  is 
based,  and  from  those  which  spring  from  it,  we 
cannot  wonder  at  the  remarkable  changes  wrought 
in  the  softer  and  more  yielding  tissues  of  the  kid- 
ney by  the  same  means.  Hypertrophy  and  sub- 
sequent contraction  of  the  intra-renal  fibrous 
tissue  are  probably  sufficient  of  themselves  to 
account  for  all  the  deformity  produced,  but  the 
action  of  these  causes  cannot  fail  to  be  pro- 
moted by  thrombosis  of  the  vessels,  which  is  of 
such  frequent  occurrence  in  all  cases  of  gouty 
remora. 

Gull  and  Sutton  say :  "  The  morbid  state  under 
discussion  (arterio-capillary  fibrosis)  is  allied  with 
the  conditions  of  old  age,  and  its  area  may  be  said 


ITS   CONCOMITANTS  AND   SEQUELAE  205 

hypothetically  to  correspond  with  the  '  area  vascu- 
losa.'  "1    A  statement  sufficiently  con-  ^^.^g^,^-^,. 
firmative  of  all  I  have  been  suggesting ;  capillary 

1      ,    T  tj.j-1      £      J.^  ^  xA     J.    fibrosis  cannot 

but  1  go  a  little  lurther,  and  say  that  -^^  anferen- 
during  life  it  is  impossible,  even  if  it  tiated  during 
were  desirable,  to  differentiate  the  one    I        "  .'^  ' 

'  from  senile 

condition    from   the    other,   and    that  loss  of  arterial 

•  11  P        .      •   ^     ^      ••   'J.     •         jxt     elasticity. 

senile  loss  oi  arterial  elasticity  is  suni- 
cient  to  account  for  all  those  sequential  changes, 
which,  when  excessive,  terminate  in  the  gouty  or 
cirrhotic  kidney. 

Atherosis  is  merely  one  of  those  senile  changes 
by  which  a  structured  matrix  is  replaced  by 
amorphous  material  (^vide  antea,  p.  13).  Gout,  and 
such  poisons  as  alcohol,  lead,  and  syphilis,  promote 
the  advent  of  this  change,  and  the  last-named 
poison  is  specially  responsible  for  the  end-arteritis 
so  often  present.  But  these  special  conditions  do 
not  seem  to  be  necessary  for  the  production  of  the 
gouty  kidney,  though  undoubtedly  they  precipitate 
and  intensify  all  those  sequential  changes  which 
find  their  natural  termination  in  this  structural 
alteration. 

Sir  George  Johnson's  uncontradicted  statement, 
that  the  cirrhotic  kidney  is  "  of  common  occur- 
rence  in   those  that  eat  and  drink  to   excess,"  ^ 

1  Medico- Chirurgical  Transactions,  Vol.  Iv.,  p.  296. 

2  Medical  Lectures  and  Essays,  London,  1887,  p.  680. 


206  THE   SENILE  HEART 

sufficiently  explains  the  predominance  of  hyper- 
trophy in  the  hearts  of  such  patients  ;  while  the 
fact  that  the  cirrhotic  kidney  is  not  restricted  to 
gross  feeders,  but  is  also  found  in  those  labouring 
under  *'  certain  forms  of  dyspepsia,"  ^  accounts  for 
this  affection  not  being  restricted  to  those  with 
marked  cardiac  hypertrophy.  Every  case  requires 
to  be  considered  and  explained  by  its  own  indi- 
vidual circumstances. 

It  must  be  remembered  that  dilatation  is  the 
first  stage  of  senile  cardiac  failure  {vide  antea^ 
p.  33),  and  even  when  hypertrophy  afterwards 
becomes  excessive,  the  ventricular  cavity  will 
always  be  found  increased  in  size,  though  in  some 
cases  the  mode  of  death  makes  the  post-7nortem 
appearance  of  the  heart  apparently  to  belie  this 
(so-called  concentric  hypertrophy). 

We  are  told  that  it  is  always  easy  to  differen- 
tiate the  congested  kidney  of  cardiac  failure  from 
the  cirrhotic  kidney ;  because  in  the  former  case 
the  urine  is  diminished  in  quantity,  and  there  is 
a  considerable  amount  of  albumin  present;  while 
in  the  latter  case  the  urine  is  not  diminished,  often 
greatly  increased,  and  the  albumin  is  present  in 
but  small  quantity,  often  only  as  a  mere  trace. 
This  statement  is  perfectly  correct,  and  yet  in  my 
own  experience  some  indication  of  cardiac  failure 
1  Johnson,  op.  cit.,  p.  680. 


ITS  CONCOMITANTS  AND   SEQUELS  207 

has  always  preceded  any  manifestation  of  kidney 
affection. 

In  those  rare  instances  in  which  a  lifelong  ac- 
quaintance with  all  the  details  of  the  case  has 
made  known  every  point  in  its  history,  there  is 
no  difficulty  in  ascertaining  this  with  at  least  the 
highest  probability. 

When,  however,  a  case  of  senile  heart,  seen  for 
the  first  time,  presents  a  trace  of  albumin  in  urine 
otherwise  normal  as  to  quantity  and  quality,  with- 
out any  evident  soakage  of  the  tissues,  we  are  not, 
perhaps,  justified  in  regarding  the  kidneys  as  cir- 
rhotic ;  but  we  may  be  well  assured  that  only 
careful  treatment  can  postpone,  or  possibly  pre- 
vent, such  an  untoward  ending. 

Having  been  for  nearly  all  my  professional  life 
fully  cognizant  of  the  medical  history  of  a  well- 
known  dignitary  of  a  northern  univer- 
sity,  and  having  been  for  many  years  f,eart  with 
his  occasional  medical  adviser,  I  was  p^oiaUe  dr- 

-,  ^  ^  rhotic  kid- 

well  aware  that  he  had  hard  and  tor-  ^g^^^   Fatal 

tuous    arteries    and    a    hypertrophied  ^y  urmmic 

.  coma. 

heart,  and  had  my  eyes  lully  open  to 

all   the   contingencies   likely  to   happen  in  such 

a  case. 

For  years,  however,  the  patient  went  on  the 
even  tenour  of  his  way.  At  last,  after  passing  his 
grand  climacteric,  his  heart  gave  way :  it  became 


208  THE   SENILE  HEART 

dilated,  with  a  systolic  bruit  in  the  mitral  area. 
But  not  for  some  time  after  this,  not  till  about 
four  months  only  before  the  patient's  death,  could 
any  albumin  be  detected  in  his  urine.  This  albu- 
min never  amounted  to  more  than  one-third,  often 
to  much  less,  varying  from  time  to  time,  and,  so 
far  as  I  know,  it  was  never  afterwards  absent  till 
the  end. 

The  albumin  came  with  failing  health  and  a 
broken  constitution ;  the  outward  frame  looked 
vigorous  still,  but  the  organization  was  giving 
way  at  all  points,  and  revealing  its  failure  in 
many  ways.  To  an  ordinary  observer,  it  seemed 
as  if  the  patient  would  be  at  once  restored  to  his 
pristine  vigour,  if  the  mysterious  disorder  that 
sapped  his  strength  could  be  recognized  and  re- 
moved. To  the  intelligent  eye  of  the  physician, 
there  was  but  one  possible  ending,  though  it  might 
come  in  various  ways,  and  might  be  warded  off 
for  an  uncertain  period  by  careful  and  judicious 
treatment. 

The  hard,  tortuous  arteries,  the  dilated  heart, 
and  the  albuminous  urine,  told  an  unmistakable 
tale  to  a  discerning  mind,  and  in  no  long  time 
this  was  emphasized  by  a  sudden  attack  of  blind- 
ness of  one  eye,  due  to  hemorrhage  into  the  retina 
from  rupture  of  a  vessel,  as  ascertained  on  exam- 
ination by  one  of  our  ablest  oculists. 


ITS   CONCOMITANTS  AND   SEQUELS  209 

The  patient  had  almost  constant  headache,  a 
feeling  of  intense  depression,  and  a  sensation  of 
failure,  pathetically  revealed  by  a  longing  for  a 
quiet  life,  and  release  from  the  burden  of  official 
duties  ;  a  quietness  which  he  scorned,  and  a  burden 
which  was  unfelt  in  the  plenitude  of  health,  for 
in  those  days  there  were  few  who  could  compare 
with  him  in  fulness  of  life  and  energy.  Part  of 
his  depression  was  doubtless  constitutional,  as  he 
had  suffered  similarly  at  an  earlier  period  of  life, 
but  at  this  time  there  was  every  reason  to  believe 
that  this  constitutional  depression  was  intensified 
by  imperfect  nutrition  of  the  brain,  due  to  arterial 
atherosis.  Of  this  condition  the  hard  external 
arteries,  and  especially  the  retinal  hemorrhage, 
must  be  accepted  as  a  sufficient  exponent. 

Already  the  outworks  were  sapped,  and  the 
enemy  was  marching  along  the  pathway  of  the 
arteries  towards  three  breaches  in  the  enceinte  of 
the  citadel  of  life  —  the  dilated  heart,  the  con- 
tracting kidneys,  and  the  shrinking  brain.  Which 
of  these  would  be  the  first  to  be  stormed  it  was 
impossible  to  foretell. 

There  was  nothing  to  be  done  but  to  send  the 
poor  patient  to  a  milder  climate  for  the  winter,  in 
the  hope  that  his  valuable  life  might  be  prolonged. 
A  full  and  particular  account  of  his  illness  and 
present  condition  accompanied  him  south,  and  the 


210  THE   SENILE  HEART 

programme  indicated  was  carried  out.  About  a 
month  after  I  last  saw  him  the  patient  died  some- 
what suddenly  from  ursemic  coma. 

This  case  was  in  every  respect  one  of  intense 
interest.  What  is  specially  noteworthy  is,  that 
there  is  an  absolute  certainty  that  the  hypertrophy 
of  the  heart  long  preceded  any  indication  of  kid- 
ney affection,  though  this  was  carefully  looked  for 
during  many  years;  that  the  kidney  affection 
never  became  cognizable  till  the  heart  began  to 
fail ;  and,  lastly,  that  this  cardiac  failure  was 
quite  unaccompanied  by  any  other  sign  or  symp- 
tom, apart  from  those  of  the  heart  itself,  beyond 
the  slight  albuminuria ;  in  particular,  there  never 
was  the  slightest  trace  of  dropsy,  nor  any  detect- 
able soakage  of  the  tissues. 

The  following  case  also  inculcates  the  same 
lesson :  that   even  when   hypertrophy 

Case  of  ,  .  . 

probable  ^^  the  predominant  lesion  of  the  heart 

cirrhotic  ^hc    kidney    affection    only    becomes 

fatal  from        Cognizable  when  this  organ  begins  to 

hepatic  fail. 

hemorrhage.  i        /•  t  •      • 

l^or  nearly  forty  years  I  was  inti- 
mately acquainted  with  a  gentleman,  who  ulti- 
mately died  at  the  age  of  sixty-eight,  and  I  had 
been  his  medical  attendant  for  some  considerable 
portion  of  that  time.  He  was  a  man  of  robust 
frame,  who  lived  well,  and  enjoyed  excellent 
health  up  to  a  couple  of  years  before  his  death. 


ITS   CONCOMITANTS  AND   SEQUELAE         211 

Early  in  life  this  patient's  arteries  became  large, 
hard,  and  tortuous,  and  for  quite  ten  years  before 
his  death  he  was  known  to  have  a  large  hyper- 
trophied  heart,  which  had  come  on  insidiously  and 
presented  no  symptoms.  About  five  years  before 
his  death  his  heart  began  to  falter  and  become  irreg- 
ular; it  had  commenced  to  fail.  This  irregularity 
was  never  altogether  remedied,  but  it  did  not  in- 
crease. During  all  this  time  the  state  of  the  kid- 
neys had  been  watched  most  carefully,  but  not  the 
slightest  imperfection  could  be  detected,  till  about 
two  years  before  the  patient's  death,  when  a  small 
amount  of  albumin,  little  more  than  a  trace,  was  at 
last  discovered.  Henceforward  a  trace  of  albumin 
was,  with  only  rare  and  occasional  exceptions, 
always  to  be  found  in  the  urine.  About  the  same 
time,  two  years  before  his  death,  this  patient  began 
to  suffer  from  defective  memory,  and  to  show  in 
other  ways  a  loss  of  brain  power,  of  which  he 
himself  was  painfully  conscious. 

Precisely  as  in  the  former  case,  the  enemy  had 
already  seized  the  outworks,  and  was  marching 
along  the  arteries  upon  the  citadel  of  life,  in 
which  the  same  three  breaches  had  been  made. 
In  this  case  it  was  evident  that  the  brain  had 
suffered  most,  and  it  seemed  probable  that  the 
breaking  of  the  "  golden  bowl "  would  have  closed 
the  last  scene  of  a  most  useful  and  energetic  life. 


212  THE   SENILE  HEART 

As  it  happened,  this  was  not  the  case.  For  long 
this  patient  had  suffered  from  a  contracting  liver 
without  any  marked  symptoms  beyond  constipa- 
tion and  troublesome  piles  ;  now,  however,  jaun- 
dice set  in,  and  after  a  few  months  of  suffering, 
intestinal  hemorrhage  suddenly  closed  the  scene. 

In  this  case,  also,  there  was  an  absolute  certainty 
that  cardiac  hypertrophy  had  for  many  years  pre- 
ceded any  manifestation  of  kidney  disease  ;  the 
kidney  affection  never  became  cognizable  till  the 
heart  began  to  fail ;  and,  lastly,  this  cardiac  failure 
was  unaccompanied  by  the  slightest  trace  of 
dropsy,  or  of  any  soakage  of  the  tissues. 

The  absence  of  a  post-mortem  examination  is  a 
certain  disadvantage  in  founding  any  argument 
upon  these  two  cases.  I  think,  however,  that  both 
Gull  and  Sutton  would  have  freely  acknowledged 
both  as  presenting  well-marked  clinical  symptoms 
of  arterio-capillary  fibrosis,  while  I  look  upon  them 
both  as  excellent  examples  of  senile  heart  originat- 
ing in  senile  loss  of  arterial  elasticity. 

In  all  such  cases  a  gouty  kidney  is  one  of  the 
possible  sequential  phenomena,  slowly  and  gradu- 
ally developing  itself  out  of  the  slowly  increas- 
ing venous  hypersemia,  but  never  betraying  itself 
by  sign  or  symptom  until,  from  some  cause  or 
other,  there  is  some  evident  failure  of  the  myo- 
cardium. 


ITS   CONCOMITANTS  AND   SEQUELS         213 

Even  after  this  the  cardiac  failure  is  so  slowly 
progressive  that  the  conditions  remain 

,  The  disad- 

for  long  practically  unchanged,  or  they  vantage,  as 

may  even   improve    under   treatment.  ^"^^^  ^^^  ^^^^ 

But  the  declension,  though  gradual,  is  of  regarding 

sure,  and  the  end  comes  at  last,  but  ^^\^  cirrhotic 

JctclTl€7/  CtS  Oj 

not  always  through  the  kidneys.     One  sequence  of 
advantage  of  taking  this  view  of  the  «e?ii^e 

.  .  degeneration. 

gouty  kidney  is  that  the  senile  variety 
may  be  looked  upon  as  preventible,  and  in  the 
early  stages  even  as  amenable  to  treatment.  The 
gouty  kidney  occurring  before  middle  life  is,  how- 
ever, associated  with  too  pronounced  an  arterial 
affection  to  be  treated  with  success,  though  even 
in  such  a  case  the  symptoms  may  be  ameliorated, 
and  the  end  postponed  by  judicious  care. 


CHAPTER  IX 

THE   THERAPEUTICS    OF   THE   SENILE   HEART. 
GENERALITIES 

The  heart  is  the  one  organ  of  the  body  whose 
sufferings  are  most  apt  to  disturb  the  equanimity 
even  of  the  most  imperturbable.  We  know  that 
with  each  pulsation,  life  and  intelligence  are  flashed 
to  the  farthest  outpost  of  our  frame,  and  we  also 
know  that  if  the  heart-beats  falter  for  a  second  or 
two  we  fall  to  the  ground,  pale,  limp,  and  almost 
inanimate  —  an  almost  which  speedily  becomes 
absolute,  if  from  any  cause  these  heart-beats  are 
prevented  from  resuming  their  pristine  vigour. 
With  this  knowledge  ever  before  our  eyes,  and 
clinched  by  many  a  startling  fact,  we  cannot 
wonder  that  feelings  of  alarm  are  ex- 

\Ct  y*(l )  ft  o 

troubles  ai-       citcd  by  any  deviation  from  the  nor- 
ways  alarm-     m^l  which  makes  us  cognizant  of  the 

o 

movements  oi  so  important  an  organ, 
of  which  we  are  ordinarily  so  profoundly  un- 
conscious.   Hence  palpitation,  intermission,  irregu- 

214 


THERAPEUTICS  215 

larity,  and  tremor  cordis^  all  of  which  make 
themselves  so  disagreeably  perceptible  to  our 
senses,  appeal  most  forcibly  to  the  imagination 
of  the  patient,  and  bring  him  more  certainly  to 
the  physician  than  cardiac  ailments  of  more 
serious  import  but  of  less  obtrusive  character. 

Symptoms  such  as  those  described  always,  and 
at  every  age,  indicate  some  physical  impairment,  a 
matter  of  comparatively  little  moment  in  early 
life,  but  of  very  much  more  serious  import  after 
middle  life.  We  must  not  forget,  too,  that  at  any 
age,  but  more  probably  in  advanced  life,  the 
physical  impairment  may  be  primaril}^  due  to  fail- 
ure of  the  trophic  nerve  centres.^  The  marked 
improvement  that  ordinarily  follows  treatment 
shows  that  a  primary  lesion  of  the  nerve  centre 
cannot  be  of  frequent  occurrence,  though  we  may 
accept  it  as  a  possible  explanation  of  the  intracta- 
bility of  some  of  the  cases  we  meet  with. 

Senile  diseases  are  always  degenerative,  and  tend 
to  precipitate  the  natural  termination  of  life.    The 

1  "In  the  human  body  there  is  no  mover  that  can  properly 
be  called  first,  or  whose  motion  does  not  depend  on  something 
else.  .  .  .  The  contraction  of  the  heart  is  indeed  the  cause  of 
the  circulation  of  the  blood,  and  consequently  of  the  secretion 
of  the  spirits  (as  is  supposed)  in  the  cerebellum,  etc. ;  but  with- 
out these  spirits  this  action  of  the  heart  could  not  be  performed. 
These  two  causes,  therefore,  truly  act  in  a  circle,  and  may  be 
considered  mutually  as  cause  and  effect." — Whytt,  On  Vital 
Motions,  Edinburgh,  1751,  p.  270. 


216  THE   SENILE  HEART 

object  of  treatment  in  senile  affections  is  not  there- 
fore quite  the  same  as  in  the  diseases  of  earlier  life. 
We  no  longer  hope  for  complete  restoration,  but 
we  expect  to  alleviate  suffering,  and  to  check 
decadence  ;  and  so  far  as  the  heart  is 

But  may  be 

remedied  at      concerned,  we   are   generally   able  to 
a}iy  age.  attain  both  of  these  objects  even  long 

after  the  average  limit  of  mortality  is  overpassed. 

Many  years  ago  a  gentleman  of  seventy-seven 
years  of  age  consulted  me  as  to  severe  fainting  fits 
to  which  he  was  liable.  A  distinguished  consult- 
ant, since  dead,  had  told  him  that  these  attacks 
were  due  to  fatty  degeneration  of  his  heart,  and 
that  no  treatment  would  be  of  any  avail.  I  found 
the  heart's  impulse  imperceptible,  the  sounds  faint 
but  pure,  the  arteries  firm,  but  neither  hard  nor 
tortuous ;  the  urine  was  free  from  albumin,  and  of 
average  specific  gravity.  I  explained  that,  con- 
sidering his  age  and  the  then  state  of  medical 
opinion,  his  adviser  was  perfectly  justified  in  both 
his  diagnosis  and  prognosis,  but  I  added  that 
experience  had  taught  me  that  hearts  supposed  to 
be  fatty,  were  often  only  weak,^  and  that  so  serious 
a  prognosis  could  only  be  justified  by  failure  of  treat- 
ment. The  result  of  treatment  in  this  case  was 
a  steady  improvement  in  health  and  in  force  of 
heart-beat,  and  the  patient  did  not  die  till  he 
1  Balfour,  op.  cit.^  p.  309. 


THERAPEUTICS  217 

attained  the  ripe  old  age  of  ninety,  and  then  not 
from  his  heart  at  all,  but  from  senile  asthenia. 

In  this  fight  with  mortality,  medicines  have 
no  doubt  their  place  and  power,  but  it  is  attention 
to  the  little  things  of  daily  life  —  the  little  things 
of  eating,  drinking,  and  doing  —  that  influence  the 
patient's  comfort,  and  gradually  turn  the  scale  of 
health  in  his  favour.  Herein  lies  one  of  the  great 
difficulties  in  the  way  of  successful  treatment,  for 
when  the  regulations  of  the  physician  come  to  be 
pitted  against  the  habits  of  a  lifetime,  there  is  some- 
times a  difficulty  in  securing  acquiescence. 

For  several  reasons  {vide  antea^  p.  34)  I  have 
given  the  senile  heart  the  synonym  of  the  gouty 
heart,  but  the  connection  between  the   ^  .   . 

Tvjo  varieties 

two  is  more  obvious  at  one  time  than  of  irritable 
at  another.  Thus,  some  years  ago  I  ^^''^' 
used  to  be  favoured  with  occasional  visits  from  an 
elderly  lady  with  an  irritable  and  slightly  dilated 
heart,  which  I  told  her  could  be  best  described  by 
the  term  gouty.  Then  she  used  to  turn  upon  me 
and  say,  "  But  Doctor  this  and  Doctor  that,"  for 
she  was  a  great  patron  of  doctors,  "  all  say  what 
does  Dr.  Balfour  mean  by  saying  you  have  a  gouty 
heart,  for  you  have  no  gout."  To  this  my  reply 
was,  "  So  much  the  worse  for  you  ;  if  you  were  to 
have  a  fit  of  gout,  your  heart  would  probably  be 
relieved."      And  doubtless  this  would  have  been 


218  THE   SENILE  HEART 

the  case,  quoad  the  irritability  at  least.  Years 
afterwards  this  old  lady  died,  and  I  ascertained 
that  her  irritable  heart  was  due  to  a  weakness  for 
porter  in  excess. 

Again,  I  often  see  an  old  lady,  hale  and  well 
preserved  for  her  years,  which  are  somewhere  over 
eighty.  For  long  this  patient  has  had  the  most 
pronounced  gouty  heart  of  its  kind  I  have  ever 
seen.  She  has  never  had  a  regular  fit  of  gout,  but 
her  fingers  are  all  distorted  with  Heberden's  knobs ; 
she  has  constant  dyspepsia  of  a  well-marked  gouty 
character,  and  she  has  a  weak,  irritable,  and  some- 
what dilated  heart,  whose  most  forcible  attempt  at 
a  beat  is  often  but  a  mere  flutter  for  days  at  a  time. 
Yet  she  is  a  sober,  careful-living  woman,  and  her 
heart  responds  well  to  treatment  even  at  her 
advanced  period  of  life.  I  have  never  heard  a 
doubt  hinted  as  to  the  nature  of  her  complaint, 
though  wonder  has  often  been  expressed  at  her 
apparently  marvellous  recoveries. 

These  are  opposite  extremes,  variants  of  the 
senile  heart  in  which  irritability  is  the  prevalent 
characteristic.  In  the  one  case  I  wasted  much 
good  advice  as  to  what  to  eat,  drink,  and  avoid, 
which  if  attended  to  would  have  sufficed  to  cure 
the  patient.  In  the  other  case  the  long-continued 
gouty  dyspepsia,  together  with  Heberden's  knobs 
on  her  fingers,  were  proof  enough  that  something 


■  or  ori- 
gin. 


THERAPEUTICS  219 

more  was  required  than  a  merely  dietetic  treat- 
ment. 

In  our  dealings  with  senile  heart  affections,  we 
must  not  forget  that  all  cardiac  affections  found 
in  the  old   are   not   necessarily  senile 

All  heart 

in  character,  though  they  must  all  be  affections  in 
unfavourably  modified   by   the   condi-  the  old  not 

•^  ,  necessarily 

tions  present.  At  this  moment  I  am  senile  in  char- 
acquainted  with  a  hale  old  gentleman,  "^^^^ 
of  eighty-six  years  of  age,  who  for 
sixty-six  of  these  years  is  known  to  haye  suffered 
from  a  dilated  and  hypertrophied  heart. 

Sixty-six  years  is  certainly  the  longest  period, 
in    my  experience,    mitral    regurgita- 

.      J    Long  dura- 
tion has  been  known  or  eyen  surmised   uono/some 

to  exist.     But   I  am  well  acquainted  cardiac  affec- 

tions. 

with  many  cases  in  which  cardiac 
disease  of  various  forms,  both  mitral  and  aortic 
regurgitation  and  more  rarely  mitral  obstruction, 
has  been  certainly  known  to  exist  from  youth  to 
age  for  periods  varying  from  forty  to  fifty,  or  even 
more  years,  without  any  marked  discomfort,  except 
when  compensation  has  been  temporarily  ruptured 
by  illness.  Many  of  these  sufferers  have  led  very 
active  lives ;  some  of  them  have  been  members 
of  my  own  profession,  who  have  shirked  no  work 
however  hard ;  and  it  has  seemed  to  me  that  the 
most  active  have  suffered  least.     Possibly  because 


220  THE  SENILE  HEART 

the  disease  was  not  so  serious,  certainly  to  some 
extent  because  the  heart  is  a  muscular  organ, 
and  like  all  such  organs  is  strengthened  and 
invigorated  by  exertion  not  carried  to  exhaus- 
tion. 

Irritability,  with  more  or  less  of  cardiac  uneasi- 
ness {vide  antea^  p.  35),  is  one  of  the  earliest  indi- 
cations  of   advancing  senility   of   the 

Earliest 

symptoms  of  heart.  The  patient  con  plains  of  an 
the  senile         uueasy  empty  feeling  in  the  precordial 

heart. 

region ;  sometimes  this  uneasy  feeling 
amounts  to  actual  pain  in  and  around  the  heart, 
but  a  pain  strictly  localized  and  neither  shooting 
nor  darting  in  any  direction.  Along  with  this 
uneasiness  there  is  irritability  of  the  heart's  action, 
both  as  to  rate  and  rhythm.  There  may  be 
palpitation ;  rapid  action ;  simple  intermission  at 
regular  or  irregular  intervals,  the  heart  simply 
dropping  a  beat  occasionally  ;  or  this  intermission 
may  continue  during  periods  of  longer  or  shorter 
duration,  and  may  occur  at  longer  or  shorter  inter- 
vals, and  mostly  as  the  result  of  emotion  or  of 
gastric  disturbance;  or  lastly,  the  heart's  action 
may  be  more  or  less  persistently  irregular  as  to 
rate,  rhythm,  and  force  simultaneously. 

These  phenomena  always  indicate  debility  of 
the  myocardium,  which,  left  to  itself,  sooner  or 
later   leads   to   dilatation  of   its   cavities,  after  a 


THERAPEUTICS  221 

fashion  already  explained  {vide  antea^  p.  40),  with 
all  the  serious  consequences  which  flow  from  this 
condition. 

These  sequential  events  do  not  follow  a  similar 
course  in  every  case,  but  each  follows  its  own 
course,  according  to  laws  which  may  be  more  or 
less  easily  recognized. 

One  patient  may  for  years  complain  of  nothing 
more    than   an   occasional  soreness  in 

, .  .  1111      Modes  in 

the  cardiac   region,  and  at  last  break  wUch  the 
down  suddenly,  from  what  he  flatters  ««^^^e  heart 

.  xi        •         1     ^    may  develop. 

himseii  IS  only  neurasthenia,  but 
which  turns  out  to  be  merely  a  commonplace  dila- 
tation of  the  heart.  This  may  end  slowly  by 
dropsical  asthenia  in  the  usual  way  ;  not  infre- 
quently it  terminates  in  a  fatal  attack  of  angina  of 
the  ordinary  form ;  or,  perhaps  even  more  com- 
monly, in  that  form  of  sudden  cardiac  failure 
which  may  be  called  angina  sine  dolore.  Another 
patient  may  only  complain  of  occasional  intermis- 
sion, or  of  fluttering  of  the  heart,  —  tremor  cordis^ 
—  which  annoys  him  by  its  recurrence,  and  such  a 
case  terminates  perhaps  more  often  by  an  attack 
of  cardiac  syncope  —  angina  sine  dolore  —  than  in 
any  other  way;  while  there  are  still  others  in 
whom  intermission,  irregularity,  or  tremor  cordis 
persist  for  many  years  without  any  apparent  detri- 
ment.    In  time,  however,  such  symptoms,  unless 


222  THE   SENILE  HEART 

remedied   by  treatment,  ultimately   terminate   in 
serious  cardiac  disease. 

Many  such  patients  seem  to  suffer  but  little 
from  their  ailment;  it  seems  somehow  to  escape 
their  cognizance ;  but  there  are  others,  not  more 
seriously  ill,  who  suffer  very  much  from  the  feel- 
ing of  insecurity  engendered  by  their  malady.  '•  I 
have  not  gone  to  bed  for  months,"  said  a  compara- 
tively young  woman  to  me  lately,  "  without  leav- 
ing everything  as  straight  as  possible.  I  feared 
each  night  would  be  my  last."  Yet  her  only 
detectable  malady  was  a  somewhat  marked  irreg- 
ularity of  the  heart's  action,  which  was  completely 
^    ^.  removed    after     about     one     month's 

disturbance      treatment.      Then   her  remark  to  me 
apt  to  en-         ^^^  ^^  ^  ^        different  character.     "  I 

gender  feel-  '^ 

ings  of  feel    quite  well  and  young  again.     I 

insecurity.       j^^^  ^  ^^^^  down  our  avcnue  the  other 

day   and  felt  neither  breathlessness    nor  irregu- 
larity." 

With  the  cardiac  irregularities  and  intermis- 
sions of  the  aged  there  is  so  often  a  faltering  of 
consciousness,  or  a  failure  of  muscular  power,  that, 
as  a  rule,  paralysis  or  brain  failure  is  more  dreaded 
than  failure  of  the  heart.  Yet  there  is  probably 
no  sufferer  from  tremor  cordis  who  does  not  feel 
inclined  to  exclaim  with  Sir  Walter  Scott,  "  What 
a  detestable   feeling  this   fluttering  of  the  heart 


THERAPEUTICS  IIZ 

is."  ^  We  cannot  even  flatter  ourselves  with  Sir 
Walter  that  it  is  confined  to  the  erudite  —  mor- 
hus  eruditorum  he  called  it  —  any  more  than  we 
can  nowadays  limit  with  Sydenham  the  podagra, 
upon  which  it  depends,  to  the  great  and  noble. ^ 

The  senile  heart  is,  as  we  have  seen,  a  term 
which   comprehends   many   symptoms 

.  Senile 

and  a  variety  oi  signs,  and  is  essen-  cardiac 
tially   a   cardiac    failure    based   upon  M^ure 

esseTitialli/ 

imperfect  metabolism.     It  is  therefore  i)ased  upon 
of  the  greatest  consequence  to  deter-  irnper/ect 

metabolism. 

mine  the  cause  oi  this  lailure  by  ascer- 
taining the  source  of  the  malnutrition  upon  which 
it  depends. 

1  "I  know  that  it  is  nothing  organic,  and  that  it  is  entirely 
nervous,  but  the  sickening  effects  of  it  are  dispiriting  to  a 
degree.  Is  it  the  body  brings  it  on  the  mind,  or  the  mind  that 
inflicts  it  on  the  body  ?  I  cannot  tell ;  but  it  is  a  severe  price 
to  pay  for  the  fata  morgana  w^ith  which  fancy  sometimes 
amuses  men  of  warm  imaginations.  As  to  body  and  mind,  I 
fancy  I  might  as  well  inquire  whether  the  fiddle  or  the  fiddle- 
stick makes  the  tune.  In  youth  this  complaint  used  to  throw 
me  into  involuntary  passions  of  causeless  tears.  But  I  will 
drive  it  away  in  the  country  by  exercise."  — Journal,  Vol.  i., 
p.  153. 

2  "  Gout  kills  more  rich  men  than  poor,  more  wise  men  than 
simple.  Great  kings,  emperors,  generals,  admirals,  and  phi- 
losophers have  all  died  of  gout.  Hereby  Nature  shows  her  im- 
partiality, since  those  whom  she  favours  in  one  way  she 
afflicts  in  another."  —  Works  of  Thomas  Sydenham,  M.D., 
translated  for  the  Sydenham  Society  by  R.  G.  Latham,  M.D., 
Vol.  i.,  p.  129. 


224  THE   SENILE  HEART 

In  all  these  cases  the  objective  phenomena  are 

most  to  be  relied  upon.     The  subjec- 

nciafjnosti-     ^^^^   phenomena,  the   symptoms    com- 

catmg  such  ^  ^  j      i. 

cases  objec-      plained    of,    are    chiefly  valuable    as 
tivepienom-     corroborating-  or  explaining-  the  infor- 

ena  are  o  x  o 

more  to  he        mation  derived  from  direct  observation. 
re  le   upon       j^yg^  in  regard  to  what  might  be  re- 

than  those  o  ° 

which  are        gardcd  as  SO  unmistakable  a  disease  as 
^t7  ^ .  angina  this  statement  holds  good  (vide 

subjective.  =>  o  v 

mitea^  p.  86),  however  trustworthy  the 

patient  may  be. 

In  examining  such  a  case,  with  a  view  to  treat- 
ment, the  pulse  is  one  of  those  factors 

Pulse  and        which  requires  careful  consideration; 

blood  must  ^ 

both  be  rate,  rhythm,   and   especially  tension, 

carejidiy  ^^    being   elements    of    the    greatest 

examined.  _  °      ^  ^  ^  _ 

importance  in  formulating  any  opinion 
as  to  the  exact  nature  of  the  case.  If  the  pulse  be 
small,  soft,  and  comjjressible,  the  blood  pressure  is 
low,  and  the  blood  probably  deficient  in  quantity 
(anaemia),  more  often  defective  in  quality  (spa- 
nsemia),  as  the  simple  anaemic  condition  following 
a  hemorrhage  speedily  becomes  spangemic  from  the 
absorption  of  fluid  from  the  tissues.  In  such  a 
case  we  must  inquire  into  every  possible  source  of 
loss  of  blood,  every  possible  cause  of  hsemolysis, 
and  into  every  conceivable  kind  of  interference 
with   heemogenesis.      External    hemorrhages   and 


THERAPEUTICS  225 

suppurations   are   too   obvious    drains   to   require 

more  than  a  mere  casual  mention.     At 

one  time   one  pretty  free  hemorrhage    ^^^^^^^^^ 

^  "J  o      ttons  to  be 

starts  the    organism   on    a   downward   draionfrom 

career  which  there  is  no  arrestino- ;  at  ^^^"  ^^^^^ 

^  pressure. 

another  time  an  inconspicuous  dribble 
—  very  often  intestinal  in  origin — slowly  and 
imperceptibly  drains  the  life  away.  Into  these  we 
must  not  only  inquire  by  interrogation,  but  we 
must,  so  far  as  possible,  scan  every  part  of  the 
mucous  tract  from  the  nostrils  to  anus,  and  also 
investigate  the  nature  and  frequency  of  all  the 
natural  discharges,  for  a  trifling  but  persistent 
diarrhoea  may  sap  the  strength  and  give  rise  to 
many  anomalous  symptoms ;  or,  more  insidious 
still,  an  excess  in  venery,  trifling  and  moderate  as 
it  may  seem,  may  yet  come  to  be  a  serious  drain 
when  coupled  with  the  impeded  haemogenesis  of 
advancing  age.  In  the  early  stages  of  many 
serious  complaints  which  may  start  a  senile  heart 
of  the  most  serious  description  a  great  deal  of  in- 
formation is  to  be  obtained  from  an  examination 
of  the  blood  itself.  Thus  we  have  an  increase  of 
the  white  cells  in  leucocythsemia  and  Hodgkin's 
disease ;  the  poikilocytosis  of  pernicious  anaemia ; 
or  the  mere  deficiency  of  hsemoglobin,  in  youth 
suggestive  only  of  chlorosis,  but  in  advanced  life 
hinting  at  some  obscure  malignant  disease.    Failing 

Q 


226  THE  SENILE  HEART 

any  discoverable  source  of  haemolysis,  or  any  gross 
interference  with  hsemogenesis,  we  have  always  to 
deal  with  a  certain  amount  of  dyspepsia,  which  is 
often  a  result,  and  not  a  cause,  of  the  heart  failure, 
but  which  always  materially  influences  the  compo- 
sition of  the  blood,  and  must,  therefore,  be  con- 
sidered and  provided  for  in  any  treatment  which 
is  to  prove  effectual. 

If,  on  the  other  hand,  the  pulse  is  firm,  hard, 
wiry,  and  full  between  the  beats,  this  indicates  an 
abnormally  high  blood  pressure.  That  is  the  name 
we  give  to  the  condition;  the  fact  that  underlies 
this,  and  which  is  really  what  is  indicated,  is  that 
^  ,.    ,.  the  blood  does  not  pass  so  freely  as 

Indications  ^  -^ 

to  he  drawn  it  ought  from  the  arteries  into  the 
fromt  e  veins.     This  condition  of  pulse  may 

presence  of  a  l  j 

high  blood  cocxist  with  any  of  the  conditions  just 
pressure.  referred   to,   and   this   additional   ele- 

ment in  no  ways  makes  unnecessary  our  enquiry 
into  the  state  of  the  blood  itself. 

The  normal  loss  of  arterial  elasticity,  which  ac- 
companies advancing  years,  of  necessity  increases 
peripheral  friction,  raises  the  blood  pressure,  and 
thus  increases  the  work  of  the  heart  (^vide  antea, 
p.  13).  Under  the  influence  of  rheumatism,  gout, 
or  of  such  poisons  as  alcohol,  lead,  or  syphilis, 
frequently  accompanied  by  acute  or  chronic  in- 
flammation of  one  or  other  of  the  arterial  coats, 


THERAPEUTICS  227 

or  of  all  three,  the  arteries  get  converted  into 
hard,  often  ringed  and  rigid,  tubes,  whereby  their 
elasticity  is  still  farther  diminished,  and  the  work 
of  the  heart  much  increased.  Normal  nutrition 
is  quite  sufficient  to  maintain  the  heart  intact 
under  ordinary  circumstances  ;  but  any  interfer- 
ence with  the  nutrition  of  the  heart  on  the  one 
hand,  or  any  considerable  increase  of  its  work  on 
the  other,  disturbs  the  equilibrium,  and  the  heart 
becomes  irritable,  and  it  may  be  irregular  in  its 
action,  and  slowly  dilates.  On  the  other  hand, 
if  a  similar  call  for  exertion  on  the  part  of  the 
heart  is  accompanied  by  a  superabundant  supply 
of  food  and  stimulants,  the  primary 
dilatation  1    is    speedily   followed    by  ^"^J^^^-^" 

^  'J  J     heart  by  no 

considerable  hypertrophy  of   the  left  means  icUo- 
ventricle,  and  we  have  established  the  ^«f^^«^^^^-^ 

origin. 

"  luxus  "  heart  of  the  Germans.  This 
hypertrophy  of  gourmands  is  described  by  Traube 
and  Fraentzel  as  due  to  luxurious  feeding  alone  ; 
but,  as  Cohnheim  has  wisely  said,  "  To  an  accurate 
comprehension  of  the  manner  in  which  supera- 
bundant meals  increase  the  work  of  the  heart, 
the  physiological  data  at  our  command  are  inade- 
quate." ^  There  is,  in  truth,  no  fact  in  physiology 
that  teaches  us  that  excess  of  nutriment  promotes 
cardiac  hypertrophy.     There  is  no  hypertrophy  of 

1  Cohnheim,  op.  cit.,  p.  66.        ^  Cohnheim,  op.  cit.,  p.  67. 


228  THE   SENILE  HEART 

the  heart  among  the  Strassburg  geese  stuffed  to 
repletion  to  supply  the  market  with  foie  gras^  nor 
did  any  one  ever  hear  of  a  young  porker,  fattened 
for  the  butcher,  having  enlargement  of  the  heart. 
As  an  initiative,  there  must  first  be  peripheral 
obstruction,  so  that  the  heart,  being  "more  than 
usually  exercised  in  its  office,"  ^  hypertrophies.  If 
the  call  for  extra  exertion  is  only  imperfectly 
responded  to,  because  the  heart  is  ill  nourished, 
irritability  and  dilatation  of  the  myocardium 
speedily  follow.  But  if  the  obstruction  is  consid- 
erable, and  the  blood-supply  abundantly  nutritious 
and  stimulating,  hypertrophy  follows.  Both  pro- 
cesses progress  slowly  and  gradually ;  but  the 
irritability  of  a  weak  dilating  heart  very  soon 
attracts  attention  to  itself ;  whereas,  a  hypertro- 
phied  heart  gives  rise  to  but  few  symptoms,  and 
is  apt  to  be  overlooked  and  only  discovered  acci- 
dentally, until  it  begins  to  fail.  A  heart  in  which 
the  left  ventricle  is  hypertrophied,  with  a  hard, 
firm  pulse  indicating  increased  intra-arterial  blood 
pressure,  is  often  looked  upon  as  renal  in  its  origin, 
because  frequently  found  associated  with  cirrhotic 
kidneys  (vide  antea,  p.  200).  It  is,  however,  much 
more  probably  primary,  and  the  cause  of  the  kid- 
ney affection,  not  its  result  (vide  antea,  p.  202). 

1  Lectures  on  Surgical  Pathology,  by  James  Paget,  F.R.S., 
etc.,  London,  1870,  3d  edition,  p.  49. 


THERAPEUTICS  229 

Even  in  young  and  healthy  arteries  any  increase 
of  the  blood  pressure  over  the  normal  mean  pro- 
duces rigidity  of  the  arterial  walls. ^  In  advanc- 
ing age,  therefore,  as  the  arterial  walls  become  less 
elastic,  a  comparatively  trifling  rise  of  the  intra- 
arterial blood  pressure  suffices  to  make  the  arterial 
coats  tense  and  rigid,  the  artery  rolling  like  whip- 
cord beneath  the  finger,  while  the  trifling  charac- 
ter of  the  pulsatile  movement,  coupled  with  the 
considerable  pressure  required  to  arrest  it,  suffi- 
ciently indicate  the  nature  of  the  obstacle  to  the 
ventricular  output,  and  the  consequent  embar- 
rassment to  the  heart's  action.  An  embarrassment 
of  this  character  occurring  during  the  night  is  a 
common  cause  of  cardiac  asthma,  and  evidently 
many  deaths  from  angina  sine  dolore^  whether  by 
day  or  night,  are  due  to  this  cause,  happening  as 
they  so  often  do  when  the  patient  is  at  perfect 
rest.  The  spasm  of  the  arterioles,  which  in  such 
cases  is  the  cause  of  the  rise  of  the  blood  pressure, 
may  be  reflex  from  the  stomach,  intestines,  or  some 
other  organ ;  or  it  may  be  due  to  direct  irritation 
of  the  vaso-motor  centre  in  the  medulla.  There 
is  even  reason  to  believe  that  at  times  the  rise  of 

1  "70  or  80  mm.  of  mercury  is  about  the  normal  mean 
blood  pressure  of  the  rabbit,  and  this  experiment  shows  that 
above  this  the  arteries  become  more  and  more  rigid- walled. " 
—  Roy  and  Adami,  Practitioner,  1890,  p.  351. 


230  THE   SENILE   HEART 

blood  pressure  may  be  due  to  increase  of  the  ven- 
tricular output  from  cardiac  stimulation,  and  there 
is  no  reason  to  doubt  that  cardiac  stimulation 
coupled  with  contraction  of  the  arterioles  is  a  very 
frequent  cause  of  this  rise  of  the  intra-arterial  blood 
pressure.  A  great  effect  in  this  respect  is  usually 
accorded  to  the  kidneys ;  this,  however,  can  only 
be  partially  tenable,  as  it  is  only  universally  appli- 
cable in  the  case  of  the  cirrhotic  kidney,  and  in 
that  affection  there  is  sufficient  reason  for  the  rise 
of  blood  pressure  apart  from  any  affection  of  the 
kidney,  which  it  indeed  precedes  {vide  antea^  p. 
202). 


CHAPTER  X 

THE   THERAPEUTICS    OF   THE   SENILE   HEART. 
EXERCISE   AND   DIET 

When  any  one  past  middle  life  complains  of 
symptoms  resembling  those  described  as  associated 
with,  the  senile  heart,  we  know  that,  whatever  else 
there  may  be,  there  certainly  is  failure  of  the 
myocardium.  In  such  a  case  our  first  endeavour 
must  be  to  discover  and  remove  any  possible  cause 
of  enfeeblement,  whether  that  be  an  obvious  drain 
or  merely  a  constructive  one,  nervous  exhaustion 
following  overwork  or  worry.  And  our  next 
endeavour  must  be  to  build  up  and  energize  the 
frame  generally,  and  the  heart  in  particular.  Exer- 
cise, diet,  and  medicines  are  the  three  agents  em- 
ployed to  this  end. 

Medicines   are   indispensable   in    restoring    the 

vital  balance  of   an  organism  that  has  been  lost 

through   failure    of   an   organ,    especially  if   that 

organ  be  the  heart. 

Exercise  and  diet  are,  however,  paramount   in 

231 


Of  exercise 
in  the  treat 


232  THE   SENILE  HEART 

maintaining  the  integrity  of  a  healthy  organism  ; 

and,   properly   employed,    they   are    also    of    the 

greatest  value  in  restoring  it  when  lost. 

It   seems   somewhat  of   a  paradox  to  speak  of 

exercise  as  a  treatment  for  an  organ 

which   takes   its   needful   rest  in   sec- 

mentofthe       tions,  and  that  only  for  fractions  of  a 
senile  heart.  .       ,  i       i  •   i  i     i        •      • 

minute,  and  which,  as  a  whole,  is  m 
constant  and  continuous  work  from  man's  birth  to 
his  death.  Yet  we  know  that,  like  every  other 
muscular  organ,  the  heart  is  strengthened  by 
exertion,  and  that  if  well  fed,  it  hypertrophies 
when  that  is  in  excess.  The  rational  deduction 
from  this  is  that  exercise  judiciously  employed 
may  be  profitable  to  the  strengthening  of  a  weak 
heart.  Stokes  was  the  first  to  point  out  this.  He 
recommended  graduated  exercise  as  useful  in  the 
treatment  of  those  weak  hearts  which  he  believed 
to  be  the  subjects  of  fatty  degeneration  ;  ^  and  from 
a  personal  reminiscence  of  von  Ziemssen  we  learn 
that  Stokes  also  employed  exercise  in  the  treat- 
ment of  valvular  lesions,  and  specially  insisted  on 
the  value  of  even  violent  exertion  in  the  treatment 
of  aortic  regurgitation.^  Of  late  years  Oertel  has 
done  good  service  in  directing  the  attention  of  the 

1  Diseases  of  the  Heart  and  Aorta,  Dublin,  1854,  p.  357. 

2  Verhandlungen  des  Congresses  fur  Innere  Iledicin,  Wies- 
baden, 1888,  S.  55. 


THERAPEUTICS  233 

profession  to  the  importance  of  regulated  diet  and 
exercise  in  the  treatment  of  cardiac  affections. 
Much  benefit  has  doubtless  followed  the  recogni- 
tion of  the  fact  that  the  discovery  of  a  cardiac 
murmur  is  not  a  signal  for  a  carrying  chair,  and 
need  not  be  looked  upon  as  a  bar  to  moderate 
exertion.  Yet,  though  aortic  regurgitation  is  not 
always  found  to  be  a  bar  to  even  violent  exertion, 
no  one,  I  think,  would  be  inclined  to  treat  it,  as 
Stokes  is  said  to  have  done,  by  setting  the  sufferer 
to  run  behind  his  own  carriage.^  Regular,  mod- 
erate exertion  helps  to  keep  the  myocardium  well 
nourished,  whatever  goes  beyond  tends  to  promote 
hypertrophy;  and  as  the  coronary  arteries  have 
only  a  limited  feeding  power,  when  the  myo- 
cardium gets  beyond  this,  irremediable  failure  in- 
augurates the  end  under  various  symptoms.  Nor 
is  this  the  only  risk ;  for  long-continued  exertion, 
especially  if  violent,  is,  we  know,  liable  to  be  fol- 
lowed by  muscular  collapse,  and  what  this  means 
to  a  heart  it  is  not  difficult  to  imagine.  More- 
over, scarcely  a  day  passes  in  which  the  danger 
of  irregular  exertion  is  not  exemplified  by  the 
sudden  death  of  some  one  hurrying  to  catch  a 
train  or  a  'bus  —  a  death  which  often  puts  a  sud- 
den termination  to  the  useful  lives  of  those  who 
had  never  been  known  to  ail,  although  they  had 
certainly  begun  to  age. 

1  Loo.  cit. 


234  THE  SENILE  HEART 

When,  however,  the    compensation  is   only  in- 
complete, when  exertion,  even  thouorh 

Rest  IS,  ^  °^ 

however,  slight,   brings    on    dyspnoea,    even    if 

absoiutehj        there   be   no   evident   soakag^e  of   the 

paramount  ^  ^ 

in  certain  tissues,  and  still  more  if  there  is,  then 
cases.  exercise,  even  though  carefully  gradu- 

ated, ought  to  form  no  part  of  the  treatment :  the 
risk  is  too  great.  Rest,  diet,  and  heart  tonics  will 
suffice,  if  it  be  at  all  possible,  in  time  to  restore 
the  compensation,  and  then  exercise  may  be  hope- 
fully resorted  to  as  an  adjuvant,  but  it  must  be 
begun  cautiously  and  continued  with  care.  In  a 
great  many  cases  of  senile  heart,  intermission  and 
irregularity  are  entirely  reflex  in  character,  and 
are  not  increased,  but  rather  relieved,  by  exercise, 
the  effect  of  which  is  to  lower  the  blood  pressure,^ 
and  thus  to  promote  the  fulness  and  freedom  of 
the  heart's  contraction,  as  well  as  its  force  and 
vigour.  The  exercise  not  only  benefits  the  heart 
at  the  time,  but  by  promoting  the  circulation 
through  its  walls  it  nourishes  the  muscle  and 
accumulates  energy  within  the  ganglia.  This, 
however,  can  only  happen  when  the  organism  is 
not  enfeebled,  and  when  the  heart  itself  retains 

1  Vide  Foster's  Physiology^  fifth  edition,  p.  148 :  "  At  the 
time  of  contraction  more  blood  flows  through  the  muscle,  and 
this  increased  flow  continues  for  some  little  time  after  the  con- 
traction of  the  muscle  has  ceased." 


THERAPEUTICS  235 

sufficient  recuperative  power,  and  is  more  op- 
pressed than  debilitated.  The  greater  freedom  of 
respiration  and  of  circulation  resulting  from  exer- 
cise makes  metabolism  more  perfect,  and  thus 
favourably  influences  the  manufacture  of  urea  in 
the  liver,  and  promotes  the  depuration  of  the 
blood.  Thus,  in  appropriate  cases,  not  the  heart 
only,  but  the  whole  organism,  is  the  better  for 
exercise. 

In  most  cases  of  senile  heart,  however,  rest 
will  be  found  the  most  generally  applicable 
treatment,  and  when  palpitation,  irregularity,  or 
breathlessness  follows  exertion,  rest  is  the  treat- 
ment to  which  —  at  first,  at  all  events  —  we  are 
restricted. 

The  question  of  exercise  must  always  be  care- 
fully considered  in  relation  to  each  special  case, 
and  thereafter  adapted  and  regulated  in  accord- 
ance with  its  requirements.  But,  while  in  regard 
to  the  relief  of  symptoms  the  question  of  exercise 
always  requires  careful  consideration,  there  is  no 
doubt  whatever  that  as  a  preventative  of  many  of 
the  evils  associated  with  the  senile  heart  it  holds  a 
most  important  place  ;  not  the  foremost  place,  nor 
the  paramount  position,  for  that  belongs  to  tem- 
perance alone,  which  even  without  exercise  can 
maintain  health,  if  it  cannot  bestow  strength  nor 
ensure  longevity.     Of  this  a  late  eminent  physi- 


236  THE   SENILE  HEART 

cian  was  a  notable  example,  and  there  is  not  one 
of  us  who  cannot  call  to  mind  many  similar  in- 
stances. 

Temperance  —  moderation  in  all  things — is  the 

true  secret  for  preserving  a  7mn%  sana  in  corpore 

sano  ;  and  if  it  be  not  a  certain  pass- 

imr>ortance  of     ^^^  ^^  longevity,  it  at  least  enables 

temperance.       ^  o         j  ^ 

US  to  live  healthily  for  as  long  as 
we  may.  In  these  fin  de  siecle  days,  when  every 
doctrine  is  a  fad  and  gets  pushed  to  an  ex- 
treme, there  are  multitudes  eager  to  enforce  a 
rabid  teetotalism  upon  all  their  fellow-men  as  the 
only  panacea  for  health,  happiness,  and  longevity. 
But  if  we  except  the  votaries  of  vegetarianism, 
which  is  more  of  a  cult  than  a  protest  against 
excess,  I  know  of  no  society  that  inculcates,  by 
precept  or  example,  temperance  in  regard  to  food  ; 
yet  there  is  nothing  ages  a  man  or  a  woman  so 
rapidly,  there  is  nothing  that  shortens  life  so 
certainly,  and  there  is  nothing  that  embitters  the 
latter  days  of  life  so  much  as  over-indulgence  in 
food.  To  those  who  can  afford  thus  to  transgress 
— to  the  well-to-do  —  excess  in  food  is  a  much 
more  serious  menace  to  health  and  life  than  excess 
in  drink,  and  it  is  specially  so  in  respect  of  senile 
affections  of  the  heart,  some  of  which  have  been 
distinctly  recognized  to  owe  their  origin  to  over- 
indulgence, while  all  are  distinctly  aggravated 
by  it. 


THERAPEUTICS  237 

All   those  who   after   middle   life   complain  of 
cardiac  symptoms  require  to  be  dieted   ^^^^^^^^  ^^g_ 
for  some  reason  or  other ;    the  condi-  taries  may  he 
tion   of   the   patient   and   his   leading  '^^"^^^ 
symptoms   supply  the  indications   for   which   we 
have  to  provide. 

The  larger  number  of  such  patients  are  either 
at  their  normal  weight  or  slightly  below  it ;  they 
often  suffer  very  considerably  from  intermission 
or  irregularity  of  the  heart's  action,  with  breath- 
lessness  on  exertion.  These  require  careful  regu- 
lation of  a  normal  dietary  presently  to  be  specified. 
A  smaller  number  are  over  their  normal  weight,  — 
obese,  —  and  suffer  more  from  breathlessness  and 
less  from  irregularity  than  the  preceding  class  of 
cases.  These  require  to  be  specially  dieted  and 
cared  for,  so  as  to  remove  the  obesity  without 
diminishing  the  cardiac  energy  or  the  strength 
of  the  myocardium.  Lastly,  we  have  those  in 
whom  there  is  more  evident  failure  of  the  myo- 
cardium. There  may  not  be  so  much  trouble  from 
intermission  and  irregularity,  but  the  signs  of 
cardiac  dilatation  are  more  marked  than  in  either 
of  the  preceding  classes  of  cases,  and  there  are 
more  or  less  evident  indications  of  soakage  of  the 
tissues.  Such  cases  require  to  have  a  specially  dry 
diet  prescribed  for  them. 

In  all  cases  where  diet  and  dietaries  come  into 


238  THE  SENILE  HEART 

question,  the  first  point  of  importance  is  to  divide 

the   day  properly,  so   that  there   may 

Number  of       ^^  ^  sufficient   interval   between   the 

meals  and 

length  of  mcals.      This  is  a  matter  of  absolute 

interval  he-       necessity  to  sccure  perfect  digestion. 

tween  them.  *^  x  o 

Three   things    greatly   disturb  gastric 

comfort,  —  too  large  a  meal,  too  short  an  interval 
between  the  meals,  and,  lastly,  the  ingestion  of 
food  into  a  stomach  still  digesting.  If  the  heart 
is  weak,  the  discomfort  induced  by  such  irregu- 
larities is,  after  middle  life,  more  apt  to  be  felt  in 
connection  with  that  organ  than  in  the  stomach 
itself.  In  health,  the  stomach  empties  itself  in 
from  three  to  four  hours  after  the  ingestion  of  a 
meal,  and  requires  an  hour's  rest  before  a  further 
supply  is  introduced.  In  those  with  weak  hearts 
and  feeble  circulations,  the  digestion  is  necessarily 
somewhat  slower ;  hence  the  first  rule  to  lay  down 
is  :  There  must  not  he  less  than  jive  hours  between 
each  meal}  This  allows  of  three  meals  in  the  day, 
Avith  a  sufficient  interval  after  the  last  meal  to 
permit  its  digestion  to  be  well  advanced  before 

1  Abercrombie  says :  "If  digestion  goes  on  more  slowly  and 
more  imperfectly  than  in  the  healthy  state,  another  impor- 
tant rule  will  be,  not  to  take  in  additional  food  until  time  has 
been  given  for  the  solution  of  the  former.  If  the  healthy  period 
be  four  or  five  hours,  the  dyspeptic  should  probably  allow  six 
or  seven."  —  Pathological  and  Practical  Besearches  on  Dis- 
eases of  the  Stomach,  London,  1837,  3d  edition,  p.  72. 


THERAPEUTICS  239 

retiring  to  rest,  which  tends  to  ensure  a  quiet  and 
restful  night.  The  next  matter  of  importance  to 
remember  is,  that  the  ingestion  of  solid  food  into 
a  stomach  still  engaged  in  digesting  a  former  meal 
arrests  the  process  and  provokes  the  formation  of 
flatulence ;  hence  the  second  rule  to  be  laid  down 
is  :  No  solid  food  of  any  hind  is  to  he  taken  between 
meals.  This  rule  is  absolute  ;  not  a  morsel  of 
cake,  or  of  biscuit,  or  any  similar  trifle,  is  to  be 
ingested  between  meals.  There  is  nothing  so 
destructive  of  gastric  comfort  as  the  continual 
pecking  induced  by  gouty  bulimia.  This  prohi- 
bition does  not  extend  to  fluids,  which,  taken  hot 
about  three  or  four  hours  after  a  meal,  often  start 
afresh  a  flagging  digestion,  wash  the  remains  of 
the  meal  out  of  the  stomach,  and  so  prepare  that 
organ  for  its  needed  rest. 

The  third  rule  to  be  remembered  is  :  All  inva- 
lids should  have  their  most  important  meal  in  the 
middle  of  the  day.  They  should  only  have  a 
light  meal  in  the  evening. 

All  those  with  weak  hearts  have  feeble  diges- 
tion, because  the  gastric  juice  is  both  deficient  in 
quantity  and  defective  in  quality.  It  is  needful, 
therefore,  in  many  cases,  to  restrict  the  quantity 
of  the  food,  and  in  all  to  see  that  it  is  not  diluted 
with  too  much  fluid.  Hence  a  fourth  rule  of 
much  importance  for  the  comfort  of  cardiac  in- 


240  THE   SENILE  HEART 

valids  is  :  All  those  with  weak  hearts  should  have 
their  meals  as  dry  as  pbssihle} 

These  four  rules  are  of  great  importance  for  all 
dyspeptics  ;  but  for  the  comfort  and  relief  of  those 
with  weak  hearts  they  must  be  strictly  attended 
to.     It  may  be  well  to  recapitulate  them. 

1.    There   must  never  he  less  than  five  hours  be- 
tween each  meal. 
Rules  foT 

feeding  those         2.    No  solid  food  IS  ever  to  be  taken 
with  weak        between  meals, 

3.   All  those  with  weak  hearts  should 
have  their  principal  meal  in  the  middle  of  the  day. 

4.  All  those  with  weak  hearts  should  have  their 
meals  as  dry  as  possible. 

A  weak  heart  means  feeble  digestion ;  delay  in 
digestion  makes  all  food,  and  specially  certain 
kinds  of  foods,  prone  to  ferment  and  to  break  up 
into  injurious  acids  and  gases.  Undigested  food, 
acids,  or  gases  in  the  stomach  inhibit  a  weak  heart 
through  the  pneumogastric  nerve,  and  gives  rise 
to  intermissions,  irregularity,  tremor  cordis,  etc. 
It  is  of  consequence,  therefore,  to  knock  out  of 
the  dietary  of  such  patients  everything  likely  to 
be  difficult  of  digestion,  such  as  salted,  dried,  or 

1  "  In  affections  of  the  heart  the  most  remarkable  change  in 
respect  of  digestion  is  the  slowness  with  which  liquids  are  ab- 
sorbed by  the  stomach."  —  A  Manual  of  Diet  in  Health  and 
Disease,  by  Thomas  King  Chambers,  M.D.,  Oxen.,  etc.,  Lon- 
don, 1875,  p.  341. 


THE  RAPE  UTICS  24 1 

otherwise  preserved  meats  ;  cheese  ;  pastry,  and  all 
similar   foods   in  which   fatty   matter    ,  ^.  . 

•^  Articles 

has  undergone  prolonged  exposure  to  of  food 
heat ;    all   sweets  ;    and   nuts,    which  ^^^«^'^«&^« 

'  ^  for  those 

contain  a  quantity  of  oleaginous  mat-  icUhioeak 
ter  prone  to  become  rancid  by  keep-  ^"^^^' 
ing.  Vegetable  food  is  more  apt  to  give  rise 
to  flatulence  than  animal,  and  all  articles  belong- 
ing to  the  cabbage  tribe  are  specially  objectionable 
in  this  respect ;  but  such  roots  as  carrots,  turnips, 
and  parsnips  are  not  much  better.  Even  potatoes 
require  to  be  used  sparingly.  Fruits  possess  a 
low  nutritive  value,  but  when  suitable  they  form 
pleasant  and  agreeable  articles  of  diet  when  taken, 
as  on  the  Continent,  as  a  meal,  such  as  breakfast, 
or  as  part  of  the  mid-day  meal,  but  they  are  apt  to 
be  hurtful  when  introduced  as  a  mere  addendum 
or  dessert. 

In  treating  dietetically  those  with  weak  hearts 
no  good  is  to  be  gained  by  attempting  to  enforce 
rigid  dietetic  rules,  founded  upon  the  number  of 
grains  of  carbon  and  of  nitrogen  required  for 
carrying  on  the  operations  of  life.  We  have  to 
consult  with  our  patients  as  to  what  can,  rather 
than  to  lay  down  the  law  as  to  what  ought,  to  be 
taken,  keeping  always  the  right  of  veto  in  our 
own  hands,  as  in  many  of  these  cases  gouty 
bulimia,   and  long  perseverance  in   unrestrained 


242  THE  SENILE  HEART 

indulgence,    have     depraved    the    appetite,    and 
vitiated  its  right  of  selection. 

With    due    regard    to    idiosyncrasy,    therefore, 
which  must  always   be  respected,  we 

j^vtzclss  of 

diet  suitable  Select  for  sucli  cascs  such  white  fish  as 
for  those  with  whiting,  haddock,  skate,  sole,  or  plaice, 
rejecting  the  coarser  varieties,  such  as 
cod,  etc.  We  also  recommend  meat  with  short 
fibre,  such  as  chicken,  rabbit,  game,  mutton,  or 
well-grown  lamb,  in  preference  to  such  meats  as 
beef,  whose  fibres  are  long  and  tough.  As  few 
people  enjoy  dinner  without  a  potato,  one  well- 
boiled,  ripe,  and  mealy  potato  may  be  permitted, 
but  no  more.  Beyond  that  the  only  perfectly  safe 
vegetable  is  spinach,  in  which  there  is  not  a  particle 
of  flatulence ;  but  asparagus,  leeks,  onions,  and 
tomatoes  may  be  taken  in  moderation  if  desired. 
Peas,  beans,  and  other  leguminous  seeds  tax  the 
powers  of  digestion,  and  must  be  partaken  of 
sparingly.  On  the  other  hand,  such  seeds  are 
highly  nutritious,  and  in  their  green  state  sapid, 
and  may  be  used  in  moderation  without  dis- 
advantage ;  the  object  of  having  a  variety  not 
being  to  stimulate  to  excess,  but  to  be  able  to  re- 
place one  suitable  article  occasionally  by  another, 
even  animal  food  being  often  very  advantageously 
replaced  by  fruit  or  vegetables. 

Some   people   have  a  difficulty  in  taking  their 


THERAPEUTICS  243 

food  without  some   fluid,  but  this    must   always 
be  restricted  to  the  smallest  possible 

Fluids  at 
quantity,  never  more  than  live  ounces  mealtimes 

with  any  meal,  and  if  possible  less.  ^^^'^^  always 
If  water  be  taken  with  the  meals,  it 
should  be  sipped  as  hot  as  possible ;  if  tea,  as  at 
breakfast,  it  should  not  be  stronger  than  one 
spoonful,  100  grains,  to  the  five  ounces,  and  in- 
fused not  longer  than  three  minutes ;  coffee  may 
be  made  to  taste,  and  taken  either  noir  or  au  lait. 
Chocolate  and  cocoa  are  too  much  of  foods  for 
those  with  weak  hearts,  but  they  may  occasionally 
be  useful  if  taken  alone,  or  with  a  bit  of  dry  toast 
only;  on  the  other  hand,  the  infusion  of  cocoa 
nibs  makes  a  beverage  closely  analogous  to  tea 
and  coffee,  but  of  a  milder  and  less  stimulating 
character,  and  therefore  more  suitable  for  many. 
Alcohol  is  not  a  food  for  the  heart,  and  should 
never  be  prescribed,  except  pro  re  nata  ;  but  so 
many  of  our  patients  have  been  lifelong  imbibers 
of  alcohol  in  some  form  or  other  that  we  can 
usually  only  restrict  and  not  altogether  prohibit. 
For  those,  then,  to  whom  alcohol  is  permitted, 
half  an  ounce  of  whisky,  brandy,  or  gin  may  be 
given  in  three  or  four  ounces  of  water  twice  a  day, 
along  with  food ;  or  a  single  glass  of  port  or  sherry, 
or  a  couple  of  glasses  of  any  lighter  wine,  such  as 
hock  or  claret :  each  glass  to  measure  two  fluid 


244  THE   SENILE  HEART 

ounces ;  and  the  stronger  wines  are  restricted  be- 
cause liable  to  give  rise  to  acid  dyspepsia  if  taken 
in  larger  quantity.  For  the  same  reason  cham- 
pagne is  absolutely  forbidden  as  a  rule.  But  there 
is  so  much  idiosyncrasy  in  the  action  of  wines  that 
each  case  must  be  arranged  for  separately.  The 
only  safe  form  of  alcohol,  if  such  a  thing  can  be, 
is  pure  whisky  and  water  in  extreme  moderation. 
Small  quantities  of  alcohol  are  frequently  pre- 
scribed as  an  ordinary  stimulant  for  a  weak  heart, 
to  be  taken  repeatedly  during  the  day.  This  is  a 
most  injurious  treatment,  as,  though  the  primary 
effect  of  the  alcohol  is  stimulating,  it  depresses 
secondarily.  In  ordinary  circumstances  it  is  much 
better  to  direct  such  a  patient  to  take  two  or 
three  sips  of  hot  water,  as  hot  as  can 
Sipping  hot      j^^  swallowed,  occasionally  throughout 

water  an  .  . 

excellent  the  day;    this  will   be  found  to  have 

stimulant  for    g^j^g  ^s  sfood  an  immediate  effect  upon 

a  weak  heart.     ■•-  o 

the  heart  as  alcohol,  as  I  have  been 
assured  by  those  who  have  tried  both,  while  it  is 
entirely  without  any  secondary  ill  results. 

While  desirable  to  keep  the  meals  of  those  with 
„,  .,  .  weak  hearts  as  dry  as  possible,  it   is 

Fluids  m  *^  ^ 

moderation       equally  needful  that  a  sufficiency  of 
maybe  ^\xi(^  should  be  invested  to  maintain 

safely  taken  ° 

between  metabolism  and   keep  the   secretions, 

^^"^*'  especially  those  of  the  skin  and  kid- 


THERAPEUTICS  245 

neys,  in  good  working  order.  The  daily  allow- 
ance of  fifteen  ounces  permitted  to  be  taken  with 
the  food,  together  with  the  amount  of  water  con- 
tained in  the  food  itself,  will  be  found  to  be  quite 
sufficient  to  provide  for  all  the  necessary  tissue 
changes.  But  if  thirst  be  complained  of,  half  a 
pint  of  hot  water  may  be  sipped  about  four  hours 
after  each  meal,  or  only  after  the  principal  meal ; 
this  will  wash  all  the  debris  and  refuse  acids  out 
of  the  stomach  and  prepare  it  for  its  rest.  Taken 
thus,  on  an  empty,  or  nearly  empty,  stomach, 
water  is  readily  absorbed,  passes  straight  to  the 
kidneys,  and  is  not  liable  either  to  raise  the  blood 
pressure  or  to  embarrass  the  heart,  if  taken  in 
moderation.  Hot  water,  as  hot  as  can  be  sipped, 
quenches  thirst  much  better  than  cold,  which  is 
of  little  avail.  Small  bits  of  ice  to  suck  are  also 
useful,  but  the  tepid  water  resulting  from  the 
melting  ice  must  be  spat  out,  as,  if  swallowed,  it 
sickens.  It  is  often  agreeable  for  such  thirsty 
souls  to  suck  a  slice  of  lemon,  and  they  find  it 
useful.  After  all,  thirst  usually  depends  upon  the 
catarrhal  dyspepsia  so  commonly  present  in  all 
such  cases,  and  it  ceases  shortly  after  the  dietary 
has  been  carefully  regulated. 

To  relieve  a  weak  heart,  we  must  not  only  keep 
the  meals  dry,  but  it  is  also  needful  to  limit  the 
quantity  of  solids.     For  many  years  I  have  been 


246  THE  SENILE  HEART 

in  the  habit  of  prescribing  the  following  dietary, 

as  one  useful  to  begin  with,  generally 

solid  food  to      sufficient,   and   which    can    be    easily 

he  aiioioed.        ^Q^^f.^^  if  this  be  found  needful :  — 

Breakfast^  8.30 :  One  small  slice  of  dry  toast, 
weighing  about  an  ounce  and  a  half,  with  butter; 
one  soft-boiled  or  poached  Qgg^  or  half  a  small 
haddock,  or  its  equivalent  in  any  other  fresh  white 
fish ;  with  from  three  to  five  ounces  of  tea  or 
coffee,  with  cream  and  sugar.  If  there  be  any 
difficulty  about  the  tea,  it  may  be  replaced  by  a 
similar  quantity  of  infusion  of  cocoa  nibs,  or  milk 
and  hot  water,  or  cream  and  seltzer  water.  Some 
prefer  oatmeal  porridge,  with  milk  or  cream, 
and  in  ordinary  circumstances  this  need  not  be 
objected  to,  provided  not  more  than  four  or  five 
ounces  of  milk  be  taken,  and  the  porridge  be  not 
more  in  quantity  than  three  or  four  ounces  of  oat- 
meal, well  boiled ;  provided,  also,  that  porridge 
alone  be  taken,  and  not  porridge  first,  followed  by 
tea,  toast,  etc.,  which  is  destructive  of  all  comfort, 
both  for  stomach  and  heart. 

The  principal  meal  of  the  day,  whether  it  is 
called  lunch  or  dinner^  should  be  taken  about  1.30 
or  2  o'clock,  and  may  consist  of  two  courses,  not 
more  —  fish  and  meat,  or  fish  and  pudding,  or 
meat  and  pudding.  SoupSy  pastry^  pickles^  and 
cheese  are  absolutely  forbidden.     White   fish   and 


THERAPEUTICS  247 

meat  with  short  fibres  are  preferred.  Half  a 
haddock,  or  its  equivalent  in  any  other  white 
fish,  boiled  in  milk,  steamed,  or  broiled,  never 
fried;  wing  and  part  of  the  breast  of  a  chicken, 
or  its  equivalent  in  sweetbreads,  tripe,  rabbit, 
game,  or  mutton ;  one  single  potato,  or  a  little 
spinach.  For  pudding,  any  form  of  simple  milk 
pudding  may  be  taken,  or  about  half  a  pound 
of  such  fruits  as  pears,  apples,  grapes,  etc.,  either 
cooked  or  uncooked.  During  this  meal  four 
or  five  ounces  of  hot  water  may  be  sipped  if 
desired. 

From  5  to  6,  three  or  four  ounces  of  tea  may  be 
taken  if  desired,  infused  as  in  the  morning,  not 
longer  than  four  minutes,  and  with  cream  and  sugar 
if  wished ;  but  no  solid  food  must  be  taken  with  it, 
not  even  a  morsel  of  cake  or  biscuit.  If  there  be 
any  difficulty  about  the  tea,  four  or  five  ounces  of 
hot  water  may  be  substituted  for  it,  and  if  there 
seem  any  need  for  a  stimulant  at  this  time,  a  tea- 
spoonful  of  Liebig's  extract  of  beef  may  be  stirred 
into  it. 

Supper^  or  the  last  meal  of  the  day,  must  always 
be  a  light  meal.  It  should  be  taken  about  7,  and 
may  consist  of  white  fish  and  a  potato,  or  toast, 
with  butter,  or  some  milk  pudding,  or  bread  and 
milk,  or  Revalenta,  made  with  milk  or  with  Lie- 
big's extract  of  beef.     At  bedtime,  four   or   five 


248  THE   SENILE  HEART 

ounces  of  hot  water  will  soothe  the  stomach,  pro- 
mote sleep,  and  pave  the  way  for  a  comfortable 
breakfast  next  morning. 

On  such  a  dietary  a  weak  digestion  from  a 
feeble  heart  will  gradually  recover  its  tone,  and 
the  patient  will  feel  comfortable,  instead  of  being 
puffy  and  oppressed  after  meals,  with  an  irregular 
and  tumbling  heart.  The  patient  usually  loses 
weight  at  first,  from  the  circulation  recovering  its 
tone  and  reabsorbing  the  oedematous  soakage, 
which,  spread  over  every  interstice  of  the  body, 
often  amounts  to  a  good  few  pounds  before  it 
makes  itself  in  any  way  perceptible  as  a  localized 
oedema. 

Those  who  have  been  slowly  wasting  from  im- 
paired digestion  gain  flesh  from  the  improve- 
ment in  this  function,  while  an  obese  person 
gets  thinner,  from  the  cutting  off  of  excesses 
and  the  diminution  of  the  fluid  taken  with  each 
meal.^  In  both  an  equilibrium  is  established  as 
soon  as  the  average  normal  weight  is  reached. 
Should  this  not  be  the  case,  we  must  first  ascer- 
tain that  the  dietary  has  been  strictly  followed, 
and   then   proceed   to   alter   it   in   the   necessary 

1  By  means  of  a  similar  dietary  the  patient  whose  pulse 
tracing  is  given  at  Fig.  4,  p.  49,  was  brought  down  comfortably 
from  over  20  stone  to  under  14  stone,  in  spite  of  his  dilated 
heart. 


THERAPEUTICS  249 

direction.  If  the  patient  has  been  losing  flesh 
too  rapidly,  the  diet  must  be  made  more  nutri- 
tious ;  this  is  seldom  required.  On  the  other 
hand,  obesity  may  be  slow  in  decreasing,  and  this 
will  only  require  a  little  more  self-denial,  espe- 
cially as  to  fluids.  A  mixed  diet  is  always  best 
for  the  maintenance  of  health,  and  if  animal 
fats  are  not  too  much  indulged  in,  the  carbo- 
hydrates in  the  diet  indicated  will  not  be  found 
too  much. 

Those  who  are  above  the  normal  weight,  and 
are  troubled  with  breathlessness,  or  other  symp- 
tom referrible  to  the  heart,  are  often  set  down  as 
having  fatty  hearts,  and  no  doubt  they  have  of  a 
kind.  A  heart  is  said  to  be  fattily  degenerated 
when  the  protoplasm  of  the  fibres  composing  its 
myocardium  becomes  converted  into  fatty  granules 
by  retrograde  metamorphosis  due  to  defective  nutri- 
tion. This  arises  from  various  causes  ;  it  occurs  in 
connection  with  fevers,  and  other  diseases,  such  as 
pericarditis,  etc.  It  is  chiefly  of  importance  in 
connection  with  the  senile  heart,  because  it  is  so 
often  found  in  connection  with  athero- 

I  T  p  J 1  ,      •  Biaqnosis  of 

matous  disease  oi  the  coronary  arteries,  ^  .^^  ,    ^ 
and  associated  with  angina.     It  is  ab- 
solutely impossible  to  diagnosticate  fatty  degenera- 
tion of  the  heart ;  we  may  surmise  its  existence, 
but  we  can  only  be  certain  of  its  presence  when 


250  THE   SENILE   HEART 

we  see  it  post  mortem.^  We  are  often  told  that 
there  is  danger  in  treating  a  fatty  heart,  as  forci- 
ble excitement  of  the  healthy  part  of  the  fibre 
might  tear  it  from  its  connection  with  the  dis- 
eased portion.  But  a  dread  of  this  kind  would 
hamper  us  sadly  in  the  treatment  of  weak,  di- 
lated, aged  hearts,  as  the  signs  and  symptoms 
which  those  present  are  precisely  those  upon 
which  we  are  told  to  rely  in  diagnosticating  a 
fatty  heart. 

At  page  216  will  be  found  narrated  the  case  of 
an    old    sfentleman    of    seventy-seven. 

Cure  of  °  ^  v'  ' 

supposed  whose  heart  was  diagnosed  to  be  fatty 
fatty  heart.     -^^  ^^^  ^£  ^^^  ablest  observers  of  his 

day.  Yet  the  result  of  treatment  was  a  cure, 
proving  that  a  heart  supposed  to  be  fatty  was 
only  weak,  and  that  a  life  supposed  to  be  over 
only  wanted  the  fillip  of  a  few  minims  of  digitalis 
to  carry  it  on  to  almost  the  extreme  of  human 
longevity.  ^ 

1  "Die  einfache  Erfahrung,  dass  man  in  vielen  Fallen  von 
Herzdilationen  mit  starker  Unregelniassigkeit  des  Pulses  bei  der 
Section  oft  nur  eine  sehr  geringe  oder  gar  keine  Fettmetamor- 
phose  findet,  walirend  schwere  Verfettungen  der  Muskelatur 
ohne  alle  Symptome  von  Seiten  des  Herzens  verlaufen  konnen, 
die  Erfahrung  also  dass  die  Muskelverfettung  nicht  in  directen 
Verhaltniss  zur  Schwere  der  klinischen  Symptome  steht,  zwingt 
uns  ein  besonderes  Krankheitsbild  'Fettherz'  aufzugeben."  — 
Fraentzel,  Die  idiopathische  Herzvergrosserung,  Berlin,  1889, 
S.  191 ;  also  Balfour,  op.  cit.,  pp.  309  and  348. 


THERAPE  UTICS  251 

In  true  fatty  degeneration  no  benefit  can  be  ex- 
pected from  treatment,  but  I  have  never  seen 
any  detriment  follow  treatment,  even  when  the 
heart  was  ultimately  found  to  be  actually  fattily 
degenerated. 

There  is,  however,  still  another  form  of  fatty 
heart  in  which  treatment  may  be  of  the  greatest 
possible  service,  or  the  reverse,  accord- 
ing to  its  character.     I  refer  to  those  treatment  in 
who  are  obese,  whose  hearts  are  op-  o,dipositas 

covdis 

pressed  with  fat,  overlying  the  base 
and  infiltrating  the  myocardium  as  an  adi]?ositas 
cordis^  the  muscular  fibres  themselves  remaining 
healthy.  These  hearts  are  usually  somewhat 
dilated  and  hypertrophied,  occasionally  intermit- 
tent or  irregular  in  their  action.  Careful  dieting, 
cardiac  tonics,  rest  at  first,  and  regulated  exercise 
subsequently,  speedily  improve  these  hearts.  But 
obese,  gouty,  and  breathless,  without  marked 
cardiac  disturbance,  these  are  just  the  cases  apt 
to  get  sent  off  to  some  Spa,  such  as  Marienbad, 
Kissingen,  or  Tarasp,  to  get  dieted  and  washed 
out,  often  with  the  most  disastrous  results,^  the 
treatment  usual  at  such  Spas  precipitating  and 
increasing  the  dilatation  it  is  our  object  to  avert 
or  remedy. 

1  Vide  Edinburgh  Medical  Journal^  January,  1890,  p.  607 ; 

and  Fraentzel,  op.  cit.,  S.  102. 


252  THE  SENILE  HEART 

When  there  is  anasarca,  or  any  evidence  of 
,  .  ,  soakage  in  any  depending  part  of  the 
dry  diet  of  body,  it  is  of  the  greatest  importance 
^^ortan^'  h  ^^  place  the  patient,  for  a  time  at  least, 
oedema  is  on  the  driest  possible  diet,  and  not  too 
presen .  much  of  it.      This  is  carried  out  by 

allowing  for  — 

Breakfast :  One  single  slice  of  dry  toast,  weigh- 
ing about  an  ounce  and  a  half,  with  no  butter, 
but  with  a  single  cup  of  tea  infused  not  longer 
than  four  minutes,  with  cream  and  sugar,  amount- 
ing in  all  to  not  more  than  four  ounces ;  and 
nothing  else. 

Dinner :  Not  more  than  the  lean  of  two  chops, 
or  its  equivalent  in  chicken  or  fish  ;  no  vegetables ; 
as  much  dry  toast  as  may  be  desired ;  half  an 
ounce  of  brandy,  whisky,  or  Hollands,  in  three 
ounces  of  water ;  and  nothing  else. 

Supper:  As  much  dry  toast  may  be  taken  as 
is  desired,  along  with  half  an  ounce  of  brandy, 
whisky,  or  gin,  in  three  ounces  of  water ;  and 
nothing  more. 

It  is  not  very  desirable  that  a  patient  in  this 
condition  should  drink  much,  even  between  meals, 
but,  if  thirsty,  the  patient  may  be  permitted  to  sip 
slowly  three  or  four  ounces  of  hot  water  about 
an  hour  before  each  meal. 


THERAPEUTICS  253 

The  relief  obtained  by  this  strict  diet  is  both 
remarkable  and  immediate  ;  I  have  seen  a  con- 
siderable amount  of  oedema  of  the  lower  limbs 
disappear  within  twenty-four  hours,  before  there 
had  been  time  for  any  change  in  the  heart,  which 
was  feeble  and  dilated. 

Most  of  our  patients  have  been  very  self- 
indulgent,  and  are  prone  to  assail  us  with  loud 
complaints  of  being  starved.  They  scarcely  realize 
that  both  life  and  comfort  depend  upon  strict 
adherence  to  the  regulations  laid  down,  and  even 
while  benefiting  by  the  diet,  are  anxious  to  have 
the  rules  relaxed.  "  O  doctor,"  said  a  lady  whose 
feeble,  irritable  heart  had  long  been  a  trouble  to 
herself  and  me,  "  I  have  no  heart  now ;  mayn't  I 
have  a  scone  to  afternoon  tea?"  "Certainly,  if 
you  wish  it,  but  you  will  suffer  for  it."  "  Ah," 
she  said,  "  I  know  that,  for  I  have  tried  it."  As 
to  the  starvation  part  of  the  matter,  there  have 
been  so  many  exhibitions  of  fasting  men  of  late 
years,  that  for  the  first  week  or  two  even  the  most 
unreasonable  may  be  easily  controlled.  By  that 
time  our  point  will  have  been  gained,  and  the 
improvement  will  be  so  great  that  we  will  scarcely 
require  to  appeal  to  the  experience  of  Luigi  Cornaro. 
This  Venetian  gentleman  of  the  seventeenth  cen- 
tury, after  a  youth  of  excess  which  destroyed  his 
health,  restored  himself,  after  the  age  of  forty,  to 


254  THE   SENILE  HEART 

perfect  health  by  a  most  rigid  diet.     Cornaro  re- 
stricted himself  to  a  daily  allowance  of 
diet  u)07i        bread,  meat,  and  yoik  oi  egg^  amount- 
lohich  he  lived  ing  to  twelve    ounces  in  all.      With 

i7i  health  for       ,-,  tii  i  j.      t       £        j. 

o,-^/„ , ..-,  o       these    solids    he    also    took    lourteen 

sixty  years. 

ounces  of  a  light  Italian  wine  each  day. 
Upon  this  abstemious  diet  Cornaro  lived  in  perfect 
health,  both  of  body  and  mind,  for  more  than  sixty 
years,  dying  at  last  at  the  age  of  over  one  hundred 
years.^  The  only  illness  recorded  after  the  adop- 
tion of  this  hermit  fare  was  due  to  an  excess  of  a 
couple  of  ounces  in  the  day,  both  of  solids  and  of 
fluids,  which  Cornaro  was  persuaded  to  indulge  in 
at  the  instigation  of  friends,  but  to  his  own  serious 
detriment.^ 

We  must  always,  however,  blend  judgment  with 
knowledge,  and  by  occasional  weighing,  see  that 
our  patients  do  not  lose  weight  too  rapidly,  and 
that  they  maintain  an  equilibrium  when  the  normal 
has  been  gained.  Should  weight  under  such  cir- 
cumstances still  continue  to  be  lost,  enquiry  must 
be  made,  and,  if  needful,  some  change  made  in 
the  dietary. 

Tobacco  is  so  much  used  nowadays  that  any 
system  of  dietary  would  be  incomplete  which  took 

1  Sure  Methods  of  Attaining  a  Long  and  Healthful  Life.  By 
Lewis  Cornaro,  London,  1820,  23d  edition,  p.  32. 

2  Cornaro,  loc.  cit. 


THERAPEUTICS  255 

no  note  of  this.  Snuffing  and  chewing  are  both  so 
little  used,  in  this  part  of  the  world  at 
least,  that  nothing  need  be  said  of  JH^^^^q^^ 
either.  Smoking  tobacco  is  so  common 
a  habit,  and  one  so  often  indulged  in  to  excess, 
that  some  rules  seem  requisite  by  which  the  habit 
may  be  regulated.  First  of  all,  it  may  be  noted 
that  the  prevalent  habit  of  cigarette-smoking  and 
inhaling  is  the  most  seductive  as  well  as  the  most 
injurious  method  of  using  tobacco,  besides  being  a 
habit  which  seems  most  difficult  to  break.  The 
only  benefit  CA^er  claimed  for  tobacco  —  as  a  lux- 
ury—  is  that  in  some  it  soothes,  and  removes, 
exhaustion,  listlessness,  and  restlessness,  when 
these  are  brought  on  by  mental  or  bodily  fatigue. 
But  there  are  many  who  experience  no  such  effect, 
and  who  have  no  excuse  for  the  habit  save  imita- 
tion in  the  first  instance  and  the  force  of  habit 
afterwards. 

Tobacco  is  a  most  potent  narcotic  poison ;  in 
excess  it  may  cause  sickness,  vomitinsf,    ^  , 

•^  '  o'    Tobacco  most 

and  sometimes  prolonged  lethargy ;  its   dangerous  to 

, .  r\      ^  ,    •  J.    J  xi  1      « weak  heart. 

action  on  the  heart  is  exerted  tlirougn 
the  vagus,  which  it  first  stimulates  and  then  para- 
lyzes. The  stomach  and  brain  are  most  apt  to 
be  affected  by  tobacco  when  swallowed ;  smok- 
ing chiefly  affects  the  heart.  At  universities 
and  schools  of  medicine,  where   young  men  con- 


256  THE   SENILE  HEART 

gregate  and  teach  each  other  the  habit  of  smoking, 
there  is  always  ample  opportunity  of  studying  the 
effect  of  tobacco  on  the  heart.  The  tobacco  heart 
is  neither  a  functional  nor  an  organic  complaint; 
it  is  an  acute  or  chronic  poisoning  of  the  vagus, 
which  may  lead  to  actual  dilatation  of  the  heart, 
and  even  to  death  itself.  The  tobacco  heart  is 
revealed  by  many  vagaries,  from  an  acute  attack 
of  intermittence,  following  prolonged  smoking, 
and  disappearing  in  a  few  hours,  to  prolonged 
irregular  action,  violent  tachycardia,  lasting  some- 
times for  days ;  or  even  sharp  attacks  of  angina, 
following  smoking,  and  occasionally  severe  enough 
to  prove  fatal  {vide  antea^  p.  127). 

This  being  the  state  of  matters  liable  to  be  in- 
duced, even  in  young  and  healthy  hearts,  by  the 
abuse  of  tobacco,  it  may  be  readily  understood 
that  elderly  people  with  feeble  hearts  ought  to  be 
very  chary  even  as  to  its  moderate  use,  and  on  the 
first  appearance  of  any  sign  of  tobacco  poisoning, 
such  as  cardiac  intermission  or  irregularity,  the 
habit  ought  to  be  dropped  at  once  if  any  comfort 
in  the  future  is  desired. 

Narcotics  in  every  form  damage  a  weak  heart, 
and   are   too   often   the    cause    of    its 

NcLTCotics  iti 

any  form         debility;  hence  we  must  enquire  into 

injurious  to      ^\^q   habits  of   every  patient,  and   en- 

deavour  to  eliminate  those  which  are 


THERAPEUTICS  IS^J 

injurious ;  not  always  an  easy  matter,  as  some 
cling  to  habit  with  an  intensity  which  overrides 
even  the  love  of  life.  Of  no  habit  can  this  be 
more  truly  said  than  of  the  abuse  of  opium  in 
all  its  many  forms.  To  attempt  to  restore  the 
dilated  heart  of  an  opium-eater  who  will  not  for- 
swear his  habit  is  even  more  hopeless  a  task  than 
to  make  the  same  attempt  in  the  case  of  a  beer- 
soaker  or  an  inveterate  dram-drinker.  I  well 
remember  telling  a  gentleman  whose  dilated  heart 
I  had  for  some  time  been  treating  in  vain  that 
I  was  sure  he  had  not  been  quite  open  with  me, 
as  I  could  not  obtain  the  expected  result  from 
the  remedies  prescribed,  and  that  I  was  quite 
certain  I  would  not  have  been  disappointed  but 
for  the  existence  of  some  unrevealed  obstacle. 
This  appeal  to  his  conscience  produced  the  not 
unexpected  confession,  "Well,  to  tell  you  the 
truth,  I  take  a  good  deal  of  whisky  at  night." 
The  obstacle  once  revealed  and  removed,  the  hap- 
piest results,  I  am  glad  to  say,  speedily  followed. 


CHAPTER  XI 

THE  THERAPEUTICS  OF  THE  SENILE  HEART. 
DRUGS  LIKELY  TO  BE  USEFUL,  AND  HOW  TO 
USE   THEM 

All  the  various  symptoms  connected  with  the 
senile  heart  may  be  looked  upon  as  indicating 
cardiac  failure,  with  sequential  complications,  and 
the  treatment  must  therefore  be  tonic,  with  certain 
modifications. 

The  drugs  useful  as  cardiac  tonics  are  but  few  in 
number,  but  of  great  value. 

Digitalis  is  the  foremost  of   all  cardiac  tonics. 

It  gives  its  name  to  a  whole  group  of 

i(fi  a  IS  remedies  with  similar  actions,  only  one 

princeps  of  which  comes  within  a  measurable 

o/^car  lac        distance  of  itself  in  the  possession  of 

valuable  and  reliable  properties.     An 

indigenous  drug  of  the  very  highest  value,  and 

known  for  more  tlian  a  hundred  years  as  a  most 

reliable  remedy  in  dropsies,  its  action  was  so  little 

understood,  even  so  recently  as  twenty  years  ago, 

258 


THERAPEUTICS  259 

that  it  was  called  the  opium  of  the  heart,  and 
looked  upon  as  a  most  powerful  and  dangerous 
sedative.^  And  even  yet  the  profession  are  more 
or  less  hampered  in  its  use  by  an  idea  that  pos- 
sesses it  that  digitalis  is  dangerously  cumulative. 
Digitalis,  like  Fitz-James'  blade,  is  both  "sword 
and  shield,"  and  he  who  understands  its  use  will 
never  be  disappointed  by  it,  the  very  so-called 
cumulative  action  being  but  the  necessary  result 
of  one  of  its  most  valuable  properties  when  over- 
done. Given  in  full  doses,  at  short  intervals,  dig- 
italis, like  many  other  drugs,  is  not  wholly  elimi- 
nated during  the  interval,  but  each  succeeding 
dose  reinforces  those  that  have  preceded,  till  a 
dangerous  degree  of  cardiac  contraction  may  be 
produced.^  For  this  we  should  not  blame  the 
drug,  but  the  prescriber.  Even  a  considerable 
degree  of  digitalis  contraction  does  not,  however, 
seem  to  be  dangerous  if  wittingly  produced  and 
carefully  watched.  It  takes  a  good  deal  of  dig- 
italis to  bring  a  human  heart  to  a  standstill 
in  systole.  Half-ounce  doses  of  the  tincture  of 
digitalis  used  to  be  given  safely  and  repeatedly  in 
the  treatment  of  delirium  tremens.  I,  myself,  have 
often  successfully  given  drachm  doses  of  the 
tincture  every  hour,  for  four  or  five  times,  in  the 

1  Vide  Edinburgh  3Iedical  Journal,  February,  1870,  p.  743. 

2  Fothergill,  On  Digitalis,  London,  1871,  p.  5. 


260  THE   SENILE  HEART 

precritical  collapse  of  pneumonia;  and  many  years 
ago,  in  treating  the  dilated  heart  of  a  young  chlo- 
rotic  girl,  I  kept  her  pulse  for  days  at  40,  and  her 
heart-sounds  beating  with  the  empty  tic-tac  of  an 
infant's  heart  (embryocardia).  In  this  case  all  my 
endeavours  failed  to  contract  and  cure  this  dilated 
heart,  which  always  relaxed  the  moment  the  dose 
of  digitalis  was  reduced,  apparently  from  sheer  want 
of  tone  in  the  muscle.  Persistent  treatment,  though 
it  failed  to  contract  the  heart,  yet  sufficed  to  feed 
it.  It  has  kept  well  fed  all  these  years,  and,  though 
a  loud  systolic  murmur  still  indicates  the  continu- 
ance of  dilatation,  the  patient  has  long  been  a 
happy  wife,  and  the  mother  of  several  healthy  chil- 
dren, with  no  appearance  of  any  ailment  about  her. 
What  we  were,  perforce,  reduced  to  in  this  case 
„     ,  is  all  we  should  ever  attempt  in  the 

How  to  use  ^ 

digitalis  in  case  of  Senile  hearts.  We  need  never 
seme  earts.  ^^.ttQiii^t  to  contract  and  cure  a  senile 
dilated  heart.  It  cannot  be  done,  so  there  is  no 
use  trying.  But  we  can  always  improve  the 
nutrition  of  the  dilated  myocardium,  and  in  doing 
so  we  gain  two  ends :  we  fit  the  muscle  for  the 
more  perfect  discharge  of  its  function,  and  we  en- 
able it  better  to  withstand  injurious  influences, 
reflex  or  other. 

With  this  object  in  view,  we  employ  only  mod- 
erate doses  of  digitalis,  doses  which  never  seem  to 


THERAPEUTICS  261 

have  any  cumulative  action,  or  so  rarely  and 
slightly  that  we  may  safely  continue  them  for  a 
week  or  two  without  observation  and  without  risk. 

These  doses  are  for  the  British  Pharmacopseia 
preparations ; — 

Tlie  infusion^  half  a  measured  fluid    ,.^^.^^,. 

*^  '         "^  "^  digitalis 

ounce.  which  have  no 

The  tincture,  ten  minims.  *^^'!^^'  ^  ^^^ 

'  action. 

Each  of  these  doses  is  equivalent 
to  a  little  more  than  one  giain  of  the  pow- 
dered leaves,  so  that  this  may  be  taken  as  the 
medium  dose  that  may  be  safely  administered 
ever^  twelve  hours^  without  risk  of  cumulative 
action.  This  means  that  within  that  space  of 
time  the  quantity  of  the  drug  ingested  has  been 
completely  balanced  by  that  excreted,  only  the 
tonic  influence  remaining;  that  is,  the  improved 
nutrition  of  the  myocardium  due  to  the  action  of 
the  drug  while  being  slowly  excreted.  I  have 
known  such  doses  to  be  continued  for  many 
months,  sometimes  for  years.  The  dose  of  digi- 
talis is  not,  however,  an  absolute  one,  but  is  rel- 
ative to  the  bulk  (weight)  of  the  individual,  and 
specially  to  the  amount  of  his  blood,  a  weakly 
anaemic  individual  tolerating  only  a  very  much 
smaller  dose  than  one  more  plethoric.  Now  and 
then,  too,  we  come  across  an  idiosyncrasy  which 
either  tolerates  freely  a  larger  dose,  or  resents  any 


262  THE  SENILE  HEART 

but  the  smallest.  Such  cases  are,  however,  rare; 
still,  in  view  of  their  occasional  occurrence,  it  is 
well  that  a  patient  under  treatment  for  the  first 
time  should  be  seen  now  and  then  for  the  first 
week  or  two  ;  afterwards,  when  the  measure  of 
toleration,  as  we  may  term  it,  has  been  ascer- 
tained, this  may  be  less  necessary. 

There  is  a  French  preparation  of  digitalin,  pre- 
pared by  Nativelle,  which  is  most  convenient  and 
reliable.  It  is  made  up  in  granules,  each  contain- 
ing one-quarter  of  a  milligramme  (0.003858  of  a 
grain)  of  crystallized  digitalin.  Nativelle's  crystal- 
lized digitalin  is  said  by  Brunton  to  consist  chiefly, 
if  not  entirely,  of  digitoxin,i  a  principle  having 
a  precisely  similar  action,  but  insoluble  in  water, 
and  only  sparingly  so  in  alcohol.  Be  this  as  it 
may,  twenty  years'  experience  enables  me  to  say 
that  it  is  now,  and  always  has  been,  a  thoroughly 
reliable  and  active  drug.  One  fla9on  containing 
sixty  granules  in  two  months'  time  produces  quite 
a  decided  difference  in  the  heart-beat  of  those  to 
whom  they  have  been  administered.  One  granule 
every  night  at  bedtime  is  a  perfectly  sufficient 
dose  to  produce  this  decided  tonic  effect  on  the 
heart,  and  such  a  dose  may  be  continued  as  long 
as  may  be  thought  necessary.  Now  and  then  a 
larger  dose  seems  indicated,  and  one  granule  may 

1  Lauder  Brunton' s  Fharmacology,  London,  1891,  p.  995. 


THERAPEUTICS  ,  263 

be  given  every  twelve  hours,  but  except  in  bulky 
or  plethoric  individuals  so  large  a  dose  as  this  is 
rarely  long  tolerated.  To  give  more  than  two 
granules  in  the  twenty-four  hours  is  almost  certain 
to  induce  speedy  intolerance  of  the  drug,  and  as 
a  rule  violent  sickness.  Occasionally  even  one 
granule  in  the  twenty-four  hours  is  too  large  a 
dose,  and  produces  uncomfortable  sensations.  In 
one  such  case  a  single  granule  every  forty-eight 
hours  proved  quite  an  efficient  dose,  and  as  his 
health  improved,  this  patient  was  afterwards  able 
to  continue  with  one  granule  every  twenty-four 
hours  for  several  years.  If  preferred,  Nativelle 
has  a  syrup  of  digitalin  which  contains  one-quarter 
of  a  milligramme  in  each  drachm,  and  by  using  it 
the  dose  may  be  subdivided  as  minutely  as  may  be 
desired. 

The  object  we  have  in  view  when  using  digitalis 
in  a  case  of  senile  heart  is  not  to  re-   ^^     ^.   , 

The  object 

move  dropsy,  to  slow  the  rate  of  pulsa-  we  have  in 
tion,  or  to  contract  the  cardiac  cavities,  ^^.^^;^/^.  ^^^^5^ 

digitalis  m 

but  by  the  gradual  accumulation  of  a  case  of 
trifling  advantages  to  tone  up  and  ««^^^« -^fi^^^- 
strengthen  the  cardiac  muscle  by  improving  its 
nutrition.  Gradually  the  heart  acts  with  more 
vigour,  the  circulation  improves  in  steadiness  and 
force,  any  oedema  occupying  the  tissue  spaces  is 
removed,  and  thus  the  blood  pressure  is  lowered 


264  THE   SENILE  HEART 

and  a  considerable  strain  taken  from  the  heart.^ 
For  this  purpose  only  moderate  doses  are  required, 
doses  which  can  be  continued  for  many  months 
without  any  risk  of  dangerous  accumulation,  and 
which  yet  have  a  decided  effect  in  strengthening 
the  heart,  improving  the  tone  and  elasticity  of  its 
muscle,  and  accumulating  energy  in  its  ganglia. 
Naturally  this  process  is  a  slow  one,  and  the  benefit 
is  not  for  a  time  very  obvious  to  the  recipient.  Some 
years  ago  a  friend  called  on  me  and  said,  "  Doctor, 
your  medicine  is  doing  me  no  good."  "  Of  that," 
I  said,  "  you  must  allow  me  to  be  the  best  judge." 
"But  I  feel  no  change  in  my  symptoms,  nor  any 
action  whatever  from  what  you  have  given  me."  "  I 
expected  nothing  else ;  you  are  too  impatient,"  I 
replied.  "  Were  I  to  give  you  medicine  in  such  a 
dose  as  to  produce  a  sensible  action  in  a  few  days, 
before  long  its  action  would  be  so  unpleasant  that 
you  would  either  stop  it  yourself,  or  your  ordinary 
medical  attendant  would  order  you  to  give  it  up. 
In  a  short  time  the  seeming  benefit  would  vanish, 
and  you  would  abuse  me  for  having  given  you 
medicine  which  did  not  agree  with  you,  and  which 
gave  you  no  permanent  relief.  Now,  what  I  have 
given  you  will  not  speedily  relieve  you ;  but  give 
it  time,  and  it  will  make  you  well,  and  prolong 

1  Vide  Hamilton's  Pathology,  Vol.  i.,  pp.  630  and  694 ;  also 
Edinburgh  3fedical  Journal,  September,  1889,  p.  213. 


THERAPEUTICS  265 

your  days  in  comfort.  Two  or  three  months  after 
this  you  will  say  to  your  wife  some  morning,  'Do 
you  know,  my  heart  is  not  so  troublesome  as  it 
was ;  I  begin  to  think  I  am  improving ' ;  and  six 
or  eight  months  after  this  you  will  come  to  me 
and  say,  'Doctor,  I  was  preaching  last  Sunday 
and  feel  none  the  worse  for  it.' "  And  so  it  fell 
out ;  my  friend  and  his  senile  heart  are  nowadays, 
after  the  lapse  of  five  years,  still  very  good  com- 
pany to  each  other,  which  for  many  a  day  they 
were  not. 

The   senile   heart   owes  its  peculiar   symptoms 
and  progress  to  the  difficulty  which  a  ^jiri^^is 
weakened  myocardium  finds  in  main-  mnnot  be 
taining  the  circulation  in  the  face  of  J"-^^  y  given 
the  permanent  obstacle  presented   by  hearts  loUhout 
rigidity  of  the  arterial  walls.     To  seek  ^^'^^  unhck- 
to    excite    a   heart  to  more  powerful  ing  the 
action  in  the  face  of  such  an  obstacle 
seems  fraught  with  danger ;  and  we  know,  indeed, 
that  even  moderate  digitalis  stimulation   in  such 
circumstances  is  apt  to  be  followed  by  a  worsening 
of  the  symptoms,  sometimes  by  an  increase  of  the 
cardiac  dilatation,  always  of  its  erethism.     Some 
also  object  to  the  use  of  digitalis  when  the  arteries 
are  atheromatous,  from  a  dread  of  rupturing  their 
brittle  coats.     This  last-named  danger  must  be  a 
very  infinitesimal  one,  as  such  an  accident  is  quite 


266  THE   SENILE  HEART 

unknown  to  me,  notwithstanding  a  continual  and 
free  use  of  digitalis.  But,  indeed,  the  same  means 
of  necessity  taken  to  prevent  the  increase  of 
cardiac  erethism  would  also  prevent  this  more 
serious  danger.  To  this  end  it  is  needful  in  all 
such  cases  to  combine  the  digitalis  with  some  drug 
capable  of  unlocking  the  arterioles,  and  of  promot- 
ing the  free  passage  of  the  blood  to  the  veins. 
These  drugs  are,  iodide  of  potassium,  all  the 
nitrites,  of  which  nitrous  ether,  nitrite  of  sodium, 
and  nitro-glycerine  are  those  most  commonly 
used.  Digitalis  ought  never  to  be  prescribed  in  a 
case  of  senile  heart  without  the  addition  of  one  or 
other  of  these  vascular  stimulants,  and  of  these 
iodide  of  potassium  is  the  most  generally  useful, 
acting  well  and  persistently  in  a  moderate  dose, 
and  free  from  any  objectionable  effect. 

If,  at  the  commencement  of  treatment,  the  heart 
has  been  much  neglected,  the  dilatation  consid- 
erable, and  the  irregularity  great,  it  is  very  desira- 
ble to  begin  with  larger  doses  of  digitalis  than 
those  just  recommended,  so  as  to  gain  control  over 
^  the  rate  and  rhythm  of  the  heart  as 

Large  doses  of  ^  y 

digitalis  some-  rapidly  as  possible ;  but  these  large 
times  requi-      ^^^^^  ^^^  ^^^  ^^^.     ^^  ^^  required  for 

site,  even  in  j  ~i 

case  of  senile     any  length  of  time,  and  ought  to  be 

^^^^'  pretermitted  for  at  least  a   couple  of 

days  before  the  patient  is  put  upon  the  smaller 


THERAPEUTICS  267 

closes  for  a  continuance.  Where  there  is  oedema 
of  the  lower  limbs,  a  perfectly  dry  diet  with  tonic 
doses  of  digitalis  are  often  quite  sufficient  to  re- 
move the  fluid,  and  that  in  a  very  short  time. 
But  if  the  dropsy  is  at  all  considerable,  it  must  be 
treated  as  an  ordinary  case  of  cardiac  dropsy,  and 
in  such  cases  it  is  a  great  saving  of  time  to  drain 
the  limbs.  In  all  senile  hearts,  whatever  their 
character  or  special  symptom  may  be,  we  must 
always  remember  that  digitalis  uncombined  with 
one  or  other  of  the  vascular  stimulants  is  never  so 
beneficial  as  when  it  is  so  combined,  is  certain, 
indeed,  to  produce  discomfort,  and  is  very  likely 
to  do  serious  damage. 

The  only  other  member  of  the  digitalis  group 
which  has  any  pretensions  to  rival 
digitalis  itself,  is  strophanthus  and  its  ^Zpianthus. 
active  principle  strophanthin.  Stro- 
phanthus is,  however,  so  much  more  uncertain  in 
its  action,  especially  as  to  its  feeding  or  tonic 
properties,  than  the  leading  member  of  its  group, 
that  I  have  never  felt  inclined  to  displace  our  own 
pre-eminent  and  indigenous  drug  in  its  favour. 
Strophanthin  possesses,  however,  two  advantages 
over  digitalin  :  it  is  readily  soluble  in  water,  and 
it  seem  to  act  with  great  rapidity.  There  are, 
therefore,  conditions  in  which  strophanthin  is  to 
be  preferred;  but  these  are  unusual  and  excep- 


268  THE   SENILE  HEART 

tional  at  all  times,  and  are  rarely  found  in  connec- 
tion with  the  senile  heart. 

Nux  vomica  is  an  excellent  tonic  for  the  senile 
heart  and  its  concomitants,  but  as  its  usefulness 
depends  upon  its  active  principle,  it  is  more  advan- 
tageous and  contributes  to  greater  accuracy  of 
dosage  to  employ  the  liquor  strychnince  hydro- 
chloratis  rather  than  any  of  the  cruder  prepara- 
tions. The  maximum  benefit  is  only  to  be  got 
from  any  drug  by  using  the  maximum  dose  for  a 
sufficient  length  of  time  ;  and  to  do  this  safely  with 
any  remedy,  but  especially  with  so  powerful  a 
drug  as  strychnine,  it  is  needful  to  be  both  accu- 
rate  in   the    dosage  and  regular  in  the  times   of 

administration.  Strychnine  is  cumu- 
admirable  lativc  in  its  action,  but  by  strict  adher- 
tonicfor  the      encc  to  the  rules  laid  down,  it  may  be 

used  continuously  and  safely  for  many 
years.  I  have  known  five  minims  of  the  liquor 
strychnince  (^^  of  a  grain  of  strychnine)  to  be 
taken  twice  a  day  for  over  ten  years  with  the  very 
best  results ;  at  the  end  of  that  time  symptoms  of 
saturation  began  to  appear,  and  the  strychnine 
had  to  be  discontinued.  But  it  was  no  longer 
required  ;  the  puny,  delicate,  middle-aged  woman 
is  now  both  strong  and  healthy.  It  is  only  rarely 
that  a  larger  dose  than  five  minims  of  the  liquor 
strychnince  can  be  given  daily  with  benefit;  three 


THERAPEUTICS  269 

such  doses,  fifteen  minims  instead  of  ten  in  the 
day,  are  generally  followed  by  symptoms  of  poison- 
ing in  no  long  time.  Idiosyncrasy  occasionally 
turns  up,  and  for  this  we  must  be  prepared,  but 
the  dose  indicated  is  the  maximum  dose  adminis- 
trable  to  by  far  the  larger  number  of  mankind, 
for  any  length  of  time  at  least.  In  anaemic 
patients  there  is  often  an  intolerance  of  strych- 
nine, and  if  employed  at  all,  it  has  to  be  given  in 
almost  infinitesimal  doses.  Strychnine  acts  in  two 
ways :  it  is  an  admirable  tonic  for  the  stomach, 
especially  in  those  catarrhal  conditions  accompa- 
nied with  venous  congestion,  so  commonly  pres- 
ent when  the  circulation  is  feeble.  In  this  way 
the  digestion  is  improved  and  the  blood  enriched, 
so  that  the  body  generally,  and  the  heart  in  par- 
ticular, gets  better  nourished.  Strychnine  has 
also  a  specially  stimulating  effect  on  the  nervous 
system  generally ;  consequently  it  stimulates  and 
renders  more  excitable  the  vaso-motor  centre,  and 
the  cardiac  ganglia,  probably  even  energizing  that 
primordial  power  of  spontaneous  movement  pos- 
sessed by  the  cardiac  muscular  fibre  itself  —  a 
power  which  may  be  looked  upon  as  a  remnant 
of  the  vi%  insita^  the  once  diffuse  nervous  force. 
In  virtue  of  this  action  on  the  heart  and  nerve 
centres  strychnine  increases  the  cardiac  force, 
raises  the  intra-arterial  blood  pressure,  and  is  — 


270  THE   SENILE  HEART 

next  to  digitalis  —  the  most  excellent  tonic  we 
possess  for  all  feeble  and  dilated  hearts.  In  the 
less  serious  class  of  cases  it  is  sufficient  of  itself 
to  give  tone  both  to  the  heart  and  the  system 
generally,  while  in  the  most  serious  cases  it  is  a 
most  useful  adjunct  to  digitalis. 

Ar%enic  is  another  of  our  most  valuable  tonics. 
It  is  advantageously  employed  in  many  forms  of 
disease,  and  it   is  quite  indispensable 
arsenic.  -^^  ^^  treatment  of  the  senile  heart. 

It  is  very  useful  in  those  congestive 
conditions  of  stomach  which  accompany  cardiac 
failure ;  and  its  effect  in  angina  is  sometimes 
almost  magical,  the  suffering  disappearing  like 
a  dream,  quite  apart  from  any  influence  exerted 
on  the  cardiac  failure  upon  which  that  suffering 
seemed  to  depend.  Masselot  and  Trousseau  have 
both  remarked  upon  the  increased  capacity  for 
exercise  that  follows  the  administration  of  arsenic,^ 
and  this  doubtless  depends  upon  the  same  general 
tonic  influence,  affecting  the  lungs,  heart,  and 
blood,  that  makes  breathlessness  a  thing  unknown 
to  the  Styrian  mountaineer,  and  restores  the 
blooming   coat    and    friskiness    of    youth   to    old 

1  "  J'insiste  sur  ce  phenomene  eprouve  egalement  par  M. 
Masselot,  et  signale  par  lui  en  ces  termes :  '  tres  grande  apti- 
tude a  la  inarche.'  "  —  Traite  de  Therapeutique,  par  A.  Trous- 
seau et  H.  ridoux,  Vol.  i.,  p.  312. 


THERAPE  UTICS  27 1 

and  seemingly  worn-out  horses.  The  Styrians 
are  accustomed  to  take  large  doses,  as  much 
sometimes  as  five  grains,  of  pure  arsenious  acid^ 
in  the  day,  but  such  dangerous  doses  are  by  no 
means  necessary  to  obtain  the  tonic  benefits  of  the 
drug.  Most  excellent  results  indeed  occasionally 
follow  the  prolonged  use  of  almost  infinitesimal 
doses.  I  well  remember  one  old  gentleman, 
exceedingly  sensitive  to  the  action  of  drugs,  to 
whom  the  -^-^  of  a  grain  of  arsenious  acid  was 
quite  poisonous,  but  who  could  tolerate  the  -^^-^ 
of  a  grain  without  difficulty.  After  taking  this 
minute  dose  daily  for  two  or  three  weeks,  and 
nothing  else,  for  a  dilated  and  hypertrophied 
heart  beginning  to  fail,  he  said  to  me,  "  I  don't 
know  what  benefit  you  expected  from  the  treat- 
ment, but  I  know  what  I  have  received;  I  can 
go  upstairs  much  easier  than  I  used  to  do." 
Arsenic  may  be  given  alone,  and  in  anaemic  and 
very  sensitive  patients  who  can  only  tolerate  a 
very  minute  dose  this  is  often  the  best  way  of 
employing  it.  To  these  one  granule  of  arsenious 
acid  containing  -^-^  or  ^-^  of  a  grain  may  be 
given  after  food  once  or  twice  a  day  for  many 
months  with  only  increasing  benefit.     More  usually 

^  Dr.  R.  Craig  Maclagan,  "On  the  Arsenic- eaters  of 
Styria,"  Edinburgh  Medical  Journal,  September,  1864,  pp. 
203,  206. 


272  THE   SENILE  HEART 

it  is  better  to  combine  the  arsenic  with  digitalis 
or  strychnine,  or  with  both.  In  making  any  of 
these  combinations,  the  liquor  arsenici  hydrochlo- 
rici  is  the  better  preparation  to  employ,  and  in 
combination,  with  the  liquor  strychnince  hydro- 
chloratis  it  is  the  only  one  that  ought  to  be  used, 
as  with  it  the  other  preparations,  the  liquor  arseni- 
calis^  or  the  liquor  sodii  arseniatis^  make  an  incom- 
patible and  more  or  less  unsightly  mixture.  As 
we  learn  from  the  histories  of  the  Styrian  arsenic- 
eaters,  arsenic  is  a  poison  to  which  the  system 
may  be  gradually  habituated,  so  that  even  large 
doses  may  be  taken  for  many  years,  not  only  with 
impunity,  but  with  positive  benefit.  When  given 
therefore  in  the  moderate  medicinal  dose  of  two 
or  three  minims  of  one  or  other  of  the  fluid  prepa- 
rations, we  may  safely  continue  them  twice  a  day 
for  as  long  as  we  think  needful,  without  any  mis- 
givings. Nor  need  we  have  any  dread  of  any 
danger  in  leaving  off  the  drug  after  long  con- 
tinuance, as  was  at  one  time  alleged.  A  little 
caution  may  be  required  in  commencing  its  use, 
as  idiosyncrasy  plays  a  marked  part  in  relation  to 
arsenic,  but  it  is  only  rarely  that  we  fall  in  with 
those  who  are  extra-sensitive  to  its  action. 

When  the  blood  is  deficient  in  haemoglobin,  iron 
is  a  necessity.  It  is  best  given  along  with  food, 
and  should  never  be  combined  with  digitalis,  as 


THERAPEUTICS  273 

such  a  combination  is  very  apt  to  sicken.      The 
proto-salts  of  iron  are  to  be  preferred 

■*•  Iron  useful 

to    the    per-salts,    as    they    are    more  whenh^mo- 
easily  decomposed  by  the  acids  of  the  fi^^^^m  deji- 

"...  11  -,      dent. 

gastric  juice,  and  are  thus  more  read- 
ily assimilated.      As  a  rule,  large   doses  are  not 
required  in  cases  of  feeble  or  dilated  heart. 

Intra-arterial  blood  pressure  depends  upon  the 
distension  of   the  arterial   system   by   ^^  ,  ^,    -, 

•^  *^     What  blood 

the  blood  contained  within  it.     This  pressure 

1         ,  •       'J.     J.  1        actually  is. 

vascular  turgescence,  m  its  turn,  de- 
pends upon  the  relation  between  the  amount  of 
blood  pumped  into  the  arteries  by  the  heart  and 
the  outflow  through  the  arterioles.  After  middle 
life  the  outflow  through  the  arterioles  is  hindered 
by  obsolescence  of  the  capillaries  and  by  loss  of  arte- 
rial elasticity,  and  the  blood  pressure 
is  raised  by  these  obstacles,  even  with       ^^     ^^.  . 

*/  '  pressure  origi- 

a  heart  beating  at  its  normal  rate  and  nates  trouble 
force.     A  healthy  heart  has  sufficient  /g^r?*^'^*^ 
reserve  force  to  enable  it  to  cope  suc- 
cessfully with  the  demand  for  extra  exertion  thus 
made  upon  its  powers,  and  it  thrives  upon  its  ex- 
ertion.    But  when  the  heart  is  from  any  cause 
feeble  or  ill-fed,  it  fails  to  respond,  and  it  suffers, 
its  suffering  giving  rise  to  those  varied  symptoms 
comprised  under  the   term  "  senile    heart "    (vide 
antea^  pp.  27,  35,  etc.). 


274  THE  SENILE  HEART 

As  these  sufferings  are  caused  and  maintained 
by  the  high  blood  pressure,  whatever 

Whatever  /  ^    °     ^  f  n-    r-       tt 

loivers  the         lowers  this  aiways  gives  reiiei.    Hence 
hiood  pressure  thesc  Sufferings  are  capable  of  being 

gives  relief.  .  i  p 

relieved  by  various  modes  of  treat- 
ment which  are  not  all  of  them  truly  remedial. 
Permanently  to  remove  these  sufferings,  we  must 
not  content  ourselves  with  merely  reducing  the 
blood  pressure ;  we  must  also  so  strengthen  the 
heart  as  to  enable  it  to  cope  with  a  blood  pressure 
always  over  the  normal  of  adolescence,  and  which 
is  liable  to  be  suddenly  abnormally  raised  by  many 
causes.  Cardiac  tonics  are,  therefore,  required. 
But  all  cardiac  tonics  —  except,  perhaps,  arsenic 
—  are  also  cardiac  stimulants  :  they  increase  the 
elasticity  and  contractility  of  the  heart,  and,  in 
certain  conditions,  they  improve  the  heart's  metab- 
olism by  enabling  it  to  feed  itself  with  a  larger 
blood- wave  at  a  higher  pressure.  When  the  heart 
is  feeble,  however,  this  is  just  what  cannot  be 
done.  The  whole  trouble  has  arisen  because  the 
blood  pressure  is  already  too  great  for  the  powers 
of  the  heart,  and  if  we  goad  this  feeble  organ  to 
further  exertion,  for  which  it  is  unfit,  we  either 
increase  any  dilatation  that  may  be  present,  or 
induce  erithistic  tachycardia  or  irregularity.  Car- 
diac tonics  don't  agree  ;  but  we  can  make  them 
agree  by  combining  a  vascular  stimulant  with  a 


THERAPEUTICS  275 

cardiac    stimulant;    then    things   work    smoothly. 
The  heart,  no  longer  opposed  by  an    _. 

°  ••-  ^  *^  hnportance  of 

obstacle  it  can  either  not  overcome,  or  the  combma- 
only  imperfectly  and  with  suffering,   f^^^/^^f^'^; 

•J  r  'J  o'    iQr  stimulants 

now   contracts   more    perfectly,   feeds  with  cardiac 
itself    better,    and    all    its    sufferings  Jf^^^f^^^ 

'  °      the  treatment 

vanish.  of  the  senile 

Vascular  stimulants  are  agents  ^^^^^' 
which  dilate  the  peripheral  vessels  (arterioles) 
and  so  promote  the  flow  of  blood  from  the  arteries 
into  the  veins  and  lower  the  intra-arterial  blood 
pressure.  Iodide  of  potassium  is  not,  perhaps, 
generally  regarded  as  a  vascular  stimulant,  but  in 
so  far  as  it  promotes  the  flow  through  the  arteri- 
oles, and  lowers  the  blood  pressure,  it  is  an  emi- 
nent member  of  that  group,  as  has  been  established 
experimentally,  and  duly  recognized  in  relation  to 
the  treatment  of  aneurism.^  It  is  not  rapid  in  its 
action,  but  it  is  persistent,  two  or  three  grains 
every  twelve  hours  being  quite  suf&cient  to  enable 
digitalis  to  be  given  freely  without  any  cardiac  dis- 
turbance. 

All  the  nitrites  are  vascular  stimulants.  Spirit 
of  nitrous  ether  or  nitrite  of  sodium    may  be  so 

1  Vide  Bogolepoff,  Zur  Frage  der  Physiologischen  Wirkung 
des  lodkalium,  Moskauer  Pharmacolog.  Arbeiten,  S.  125  ;  and 
Virchow's  Jahresbericht,  1876,  erster  Band,  S.  402 ;  also  Bal- 
four, op.  cit.,  second  edition,  p.  459. 


276  THE   SENILE  HEART 

employed,  but  their  action  does  not  last  so  long  as 
that  of  the  iodide  of  potassium ;  while  in  rapidity 
they  are  far  inferior  to  either  the  nitrite  of  amyl 
or  nitro-glycerine.  Besides  being  a  vascular 
stimulant,  with  all  the  actions  belonging  to  such 
remedies,  nitrite  of  amyl  is  also  an  analgesic.  A 
former  patient  who  suffered  from  intense  anginous 
pain,  accompanying  a  large  aortic  aneurism  from 
which  he  died,  always  found  the  analgesic  action 
absent  unless  the  drug  was  freshly  prepared. 
When  not  quite  fresh,  his  face  flushed,  and  all  the 
usual  symptoms  due  to  amyl  were  produced,  but 
the  pain  was  not  relieved.  Since  then  the  amyl 
has  been  retailed  in  hermetically  sealed  glass,  cap- 
sules, apparently  with  the  effect  of  retaining  the 
analgesic  properties.  The  flushing  of  the  face, 
the  fulness  of  the  head,  and  the  rapid  action  of  the 
heart  produced  by  the  amyl  are  very  disagreeable  to 
some  patients ;  they  do  not  seem  to  be  in  any  way 
injurious.  I  have  known  amyl  to  be  used  with 
great  freedom  in  angina.  One  medical  friend,  who 
suffered  much  from  angina,  connected  with  aortic 
regurgitation,  not  content  with  inhaling  it  fre- 
quently during  the  day,  used  to  soak  his  pocket 
handkerchief  in  the  amyl  and  go  to  sleep  with  it 
lying  on  his  face,  without  any  ill  results.  The 
action  of  the  amyl  is  very  evanescent,  the  smell 
is   disagreeable,    and    the    quantity  in    a    single 


THERAPEUTICS  277 

capsule  is  rather  small,  but  that  is  a  matter  easily 
remedied. 

Nitro-glycerine^  glonoin^  or  trinitrin^  is  said  to 
be  a  nitrate  of  glyceril,  but  its  action  is  that  of  a 
nitrite.  In  ordinary  medicinal  doses  of  ^L-  to  y^ 
of  a  grain  it  rapidly  lowers  the  blood  pressure  and 
relieves  the  pain  of  angina.  The  action  of  nitro- 
glycerine is  somewhat  prolonged,  from  one  to 
three  or  four  hours,  according  to  the  dose.  By 
giving  an  anginous  patient  three  or  four  doses  of 
nitro-glycerine  in  the  day  he  can  often  be  kept 
quite  free  from  his  attacks ;  it  is  well  to  give  him 
a  dose  half  an  hour  before  any  exertion  likely  to 
bring  on  an  attack,  and  also  just  before  going  to 
bed.  As  a  one  per  cent  solution  it  acts  very 
rapidly,  and  the  dose  is  from  one-half  up  to  ten  or 
more  minims.  In  the  form  of  tabellse,  made  with 
chocolate,  each  containing  the  ^oq  ^^  ^  grain,  it 
acts  nearly  as  quickly,  —  in  about  half  a  minute,  — 
if  the  lozenge  be  chewed  as  rapidly  and  perfectly 
as  possible.  The  drawbacks  to  the  use  of  nitro- 
glycerine are  its  liability  to  produce  headache, 
giddiness,  throbbing  of  the  cerebral  arteries,  and 
palpitation  of  the  heart,  but  it  is  remarkable  how 
seldom  these  are  complained  of.  In  the  form  of 
tabellse,  —  tablets  or  lozenges,  —  the  nitro-glycerine 
is  easily  carried  about,  and  is  readily  available  on 
the  slightest  indication  of  pain. 


Colchicum 


278  THE   SENILE  HEART 

Tlirouofhout    the   literature   of   cardiac   disease 
there  are  recorded  many  cases  of  ex- 
,    treme  and    distressing^   irreffularity  of 

often  of  great  o  o  j 

service  in         the  heart  at  once  relieved  by  a  fit  of 

irregularity  ^^^        ^^^     ^f    .j^^^^    ^^^^^    ^^^    ^^^^^^ 

of  the  heart.       ^ 

have  been  cured  just  as  well  and  as 
speedily  by  the  use  of  colchicum.  This  is  a 
matter  not  to  be  lost  sight  of.  The  senile  heart  is 
the  gouty  heart,  and  anti-arthritic  medication  is 
always  useful,  sometimes  of  paramount  impor- 
tance, and  it  may  always  be  combined  with  other 
necessary  remedies,  notably  with  digitalis. 

In  all  cases  of  gouty  heart  it  is  of  consequence 
to  keep  the  priince  vim  free  from  acidit}^,  and  this 
of  itself  is  often  a  cure  for  many  of  the  cardiac 
symptoms,  especially  irregularities  of  rate  and 
rhythm.  I  have  known  many  who  have  taken 
Avith  great  benefit  a  teaspoonful  of  carbonate  of 
soda,  or  of  the  bicarbonate  of  potash,  at  bedtime 
every  night  for  many  years.  This  medication  has 
seemed  to  me  to  favour  the  formation  of  Heber- 
den's  knobs,  but  it  has  undoubtedly  been  attended 
with  relief  to  the  cardiac  symptoms. 

A  thorough  alkalizing  of  the  ^^Wmos  vice  is  also 
^  readily  carried  out  by  the  use  of  Vichy 

Importance  of  "^  *^  ^ 

alkalizing  the  water,  either  plain  or  aerated.  This 
pnmae  viae.  ^^^^  either  be  taken  as  ordinary  drink, 
or  a  small  tumblerful  may  be  taken  before  break- 


THERAPEUTICS  279 

fast,  while  dressing,  and  another  about  an  hour 
before  dinner.  A  third  tumblerful,  on  going  to 
bed,  is  an  excellent  thing  for  those  Avho  are  gouty 
and  have  no  marked  cardiac  symptoms ;  but  it  is 
not  wise  for  a  heart  patient  to  go  to  bed  with  a 
full  stomach,  though  its  contents  be  only  water. 
The  thorough  alkalizing  of  the  primce  vice  is  an 
excellent  adjuvant,  and  often  of  itself  suffices  to 
remove  slight  irregularity  of  the  heart. 

Dr.  Gregory's  gouty  powder,  or  its  modern 
analogue  rhubarb,  with  the  bicarbonate  of  potash 
or  soda,  is  a  most  excellent  antacid  aperient,  as  I 
suppose  every  gouty  person  knows  full  well. 
When  there  are  symptoms  of  gastric  irritation,  the 
addition  of  bismuth  to  this  powder  is  of  great 
advantage,  and  has  often  been  successfully  em- 
ployed in  cardiac  intermittence  or  irregularity 
when  accompanied  by  such  symptoms. 

An  active  cholagogue  purge  is  one  of  the  most 
efficient  means  of  lowering^  the  blood    „,  , 

°  Cholagogue 

pressure  and  relieving  the  heart.    This  cathartics 
it  does  in  virtue  of  the  large  quantity  ^^^-^^'/^ 
of  fluid   it  drains  from  the   blood,  as  the  blood 
well  as   by  the    increased  amount  of  P^^^^'"'^^- 
blood  attracted  to  the  intestinal  mucous  membrane 
by  the  irritation  of  the  purgative.     Any  cathartic 
would  suffice  for  this,  but  a  cholagogue,  or  one 
which  acts  by  increasing  the  secretion  of  the  liver, 


280  THE   SENILE  HEART 

has  the  additional  advantage  of  directly  relieving 
the  right  side  of  the  heart.^ 

Flatulence  is  a  symptom  that  often  produces  a 
great  deal  of  distress,  not  from  mere  distension,  — 
though  that,  too,  occasionally  disturbs,  —  but  by  its 
action  on  the  heart,  causing  intermission,  irregu- 
larity, or  severe  attacks  of  tremor  cordis.  In  a 
stomach  congested  and  catarrhal  from  feeble  cir- 
culation, an  amount  of   flatulence  insufficient   to 

produce  any  feeling  of  distension  often 
Flatulence,  .  . 

its  results,        gives  rise  to  great  cardiac  uneasiness 
audits  and    disturbance    that    passes    off    at 

treatment.  . 

once  on  eructation,      inese  symptoms 

are  generally  of  reflex  origin,  but  in  long,  narrow 

chests  flatulent  distension  often  seems  to  produce 

cardiac  disturbance  by  direct  pressure.     At  least, 

it   is    not   uncommon  for  such  a  patient  —  to  all 

appearance,    and   to   his   own   feeling,  in   perfect 

health  —  on  stooping  to  pick  up  a  pencil,  or  tie  his 

shoe,  to  have  his  heart  run  off  in  a  fit  of  irregu 

larity  or  of  tremor.     So  sudden  and  unexpected  a 

seizure  is  very  alarming  to  most.     It   is  the  one 

occasion  upon  which  a  sip  of  spirits  —  whisky  or 

brandy — seems  permissible.     At   the   same   time 

half   a   drachm   of   spiritus   ammonice   aromaticus., 

with  an  equal  quantity  of  spiritus  lavandulce  com- 

1  Lauder  Brunton,  Disorders  of  Digestion.,  Macmillan  &  Co., 
London,  1886,  p.  208. 


THERAPEUTICS  281 

positus^  in  a  little  water  will  give  relief  as  certainly 
and  as  quickly,  but  it  is  not  so  easily  carried  about 
as  a  small  flask  of  spirits ;  moreover,  the  spirit  acts 
best  undiluted,  which  is  handy.  The  treatment  of 
flatulence  demands  careful  dieting,  apart  from  the 
special  needs  of  the  case  generally,  along  with  the 
persistent  use  of  the  old-fashioned  cobbler's  pill, 
the  compound  galbanum  pill  of  the  last  Edinburgh 
Pharmacopeia,  the  pilula  assafoetidce  composita  of 
the  British  Pharmacopeia. 

Narcotics  are  of  use  in  the  treatment  of  affec- 
tions of  the  senile  heart  to  relieve  pain 

NciTcotics 

and   to   procure   sleep.      In   relieving  and  their 
pain  we   generally  also   induce  sleep,  ^^^  ^^ 

.  relieve  pain. 

but    there    are    many   hypnotics    well 

fitted  to  induce  sleep  which  are  of  little  use  to 
relieve  pain.  There  is  only  one  hypnotic  which  is 
also  a  sure  analgesic,  and  that  is  opium.  Its  alka- 
loid, morphia,  acts  so  rapidly  and  certainly,  and  is 
so  readily  administered  hypodermically,  that  it 
deserves  every  confidence.  Morphia  is  a  useful 
and  reliable  remedy,  not  only  in  pain- 
ful  anp-ina,   but    also   in   those   vaso-     ^  ^^^^. 

o        '  morphia. 

motor  anginas  which  are  attended  by 
great  breathlessness  without  pain,  inasmuch  as  it 
is   not   merely   an   analgesic,    but   also    an    anti- 
spasmodic,   and   it   lowers  the    blood  pressure  by 
relaxing  the  arterioles  and  so  favouring  the  trans- 


282  THE   SENILE  HEART 

ference  of  the  blood  from  the  arteries  to  the  veins. 
Morphia  is  not  only  an  analgesic  and  anti-spas- 
modic, but  also  a  hypnotic  of  great  power,  and  as 
it  has  no  ill  effect,  either  on  the  heart  or  respira- 
tory centre,  it  may,  when  required,  be  freely  used 
for  both  purposes.  The  drawbacks  to  its  use  are 
the  headache  and  gastric  disturbance  it  is  liable  to 
produce,  and  also  the  risk  of  inducing  the  morphia 
habit.  There  is  nothing,  however,  that  can  re- 
place it  in  certain  cases,  and  in  them  there  seems 
but  little  risk  of  provoking  the  habit. 

Chloroform  is  sometimes  useful  to  relieve  pain, 

when  severe,  till  morphia  has  had  time 

Action  of         ^^    ^^^^     Chloroform  is  anaWsic   and 

chloroform.  ^ 

hypnotic  only  because  it  is  anaesthetic. 
It  relieves  pain  and  induces  sleep  only  by  produc- 
ing entire  loss  of  sensibility  to  all  external  impres- 
sions, —  a  condition  not  wholly  devoid  of  danger, 
and  requiring  to  be  carefully  watched,  as  the 
border  line  of  safety  is  so  easily  crossed.  With 
careful  dosage  there  is  no  risk  whatever  in  giving 
it  to  diseased,  feeble,  possibly,  or  actually,  fatty 
hearts.^  The  risk  is  not  in  the  drug  itself,  but  in 
its  administration. 

Chloral,  like  chloroform,  is  an  anses- 

Actionof         thetic,  and  in  virtue  of  this  property 

chloral.  '  r     i        j 

it  both  relieves  pain  and  induces  sleep. 

1  Vide  Balfour,  op.  cit.,  second  edition,  1882,  p.  308. 


THERAPEUTICS  283 

It  does  not,  however,  act  so  rapidly  as  either 
morphia  or  chloroform,  and  is  not,  therefore,  likely 
to  take  the  place  of  either.  Properly  adminis- 
tered, it  is  a  perfectly  safe  and  certain  soporific, 
and  as  such  it  has  its  use  in  certain  cases.  Lie- 
breich's  chloral  is  the  only  preparation  always 
safe,  and,  therefore,  always  to  be  used.  Fifty 
grains  of  this  will  put  all  well  people  to  sleep, 
forty  grains  will  put  to  sleep  a  great  many  who 
are  not  well.  It  is  given  off  at  the  rate  of  ten 
grains  an  hour,  so  that  after  the  lapse  of  forty 
minutes  the  organism  still  retains  over  thirty 
grains.  To  this,  if  need  be,  we  add  a  second  dose 
of  forty  grains.  This  will  put  to  sleep  a  very 
large  proportion  of  those  still  sleepless  ;  and  I 
have  never  known  any  one  resist  a  third  dose  of 
forty  grains,  nor,  I  may  add,  have  I  ever  seen  any- 
thing but  the  best  results  from  even  the  full  dose 
of  120  grains.  This  dose,  though  a  large  one,  is 
quite  within  the  limits  of  safety,  even  if  swallowed 
all  at  once.  But,  given  in  the  manner  prescribed, 
there  is  in  the  organism  at  the  end  of  120  minutes 
little  over  100  grains.  Given  in  this  way,  chloral 
is  a  perfectly  safe  and  perfectly  certain  hypnotic, 
and  there  are  cases  even  of  heart  trouble  in  which 
this  knowledge  may  be  useful.^     Both  chloral  and 

1  Kichardsoii  says  that  a  man  weighing  120  to  140  pounds  is 
thrown  into  a  deep  sleep  by  ninety  grains  of  chloral,  and  that 


284  THE   SENILE  HEART 

chloroform  lower  the   blood  pressure   by  causing 

dilatation  of  the  arterioles,  probably  by  paralyzing 

the  vaso-motor  centre. 

There   are   three   hypnotics,    pure    and   simple, 

which  deserve   attention  in  those   many  cases  of 

insomnia  which  so  often  accompanies  a  gouty  and 

feeble   heart.      The   first   of    these   is 

Action  of  paraldehyde,  a  very  reliable  hypnotic 

paraldehyde.      ■'■  o      ^  j  j  i. 

without  any  analgesic  properties. 
Under  its  use  the  blood  pressure  falls  from  paral- 
ysis of  the  vaso-motor  centre,  but  the  heart  seems 
to  be  unaffected.  Paraldehyde  may  be  given  in 
considerable  doses,  as  much  as  a  drachm  every 
hour,  till  sleep  ensues.  The  great  drawbacks  to 
its  use  are,  its  vile  taste,  which  may  be  overcome 
by  giving  it  in  an  aromatic  mixture  or  in  a  cap- 
sule, and  the  disagreeable  odour  which  the  patient 
exhales  for  the  twenty-four  hours  following  its 
ingestion,  which  nothing  seems  able  to  remedy. 
The  second  hypnotic  deserving  of  attention  is 
chloralamid.      This    is     an    excellent 

Action  of         soporific:    it   lowers   the    blood   pres- 
chloralamid.  ■*-  ^ 

sure,  but  it  also  quickens  the  heart- 
beat, and  is  thus  inferior  in  usefulness  to  the 
third  hypnotic  to  be  spoken  of  immediately. 
In   spite   of   this   drawback,   chloralamid   may  be 

the  sleep  which  follows  140  grains  is  dangerous.  —  Journal  of 
Mental  Science^  Vol.  xviii.,  p.  118. 


THERAPEUTICS  285 

given  quite  safely  to  cardiac  patients  for  many 
weeks.  It  is  not  cumulative  in  its  action,  nor 
does  use  ever  seem  to  necessitate  an  increase  of 
the  dose.  Forty  grains  is  an  efficient  dose.  This 
should  be  rubbed  up  with  spirit  (0.920  sp.  gr.) 
donee  solutio  fiat,  and  taken  with  the  addition  of 
a  little  syrup. 

The  third  hypnotic  of  importance  is  cMoralose, 
a  drug  of   quite  recent  introduction, 
but  which  promises  to  be  a  most  val-    ,f  ^^^, 

^  chloralose. 

uable  addition  to  our  armamentarium. 
Chloralose  lowers  the  blood  pressure  ;  but,  even 
in  large  doses,  it  has  no  exciting  effect  on  the 
heart,  seeming  rather  to  steady  and  regulate  the 
action  of  that  organ.  Patients  fall  asleep  quickly 
under  its  use,  and  they  waken  easily  and  refreshed. 
There  is  no  headache  and  no  gastric  disturbance, 
the  appetite  seeming  to  be  rather  improved.  Even 
when  taken  in  an  excessive  dose,  the  heart  is  never 
affected  injuriously,  the  only  result  of  an  over- 
dose being  a  certain  amount  of  intoxication.  The 
only  drawback  to  the  use  of  chloralose  is  a  ten- 
dency to  act  irregularly,  and  to  induce  nervous 
symptoms  in  hysterical  and  neuropathic  patients. 
The  dose  of  chloralose  is  from  two  to  eight  grains, 
and  it  is  best  administered  in  a  cachet.  A  very  good 
way  of  giving  chloralose  is  to  give  a  cachet  con- 
taining three  or  four  grains  at  bedtime.     Should 


286  THE   SENILE  HEART 

the  patient  have  a  good  night,  well  and  good ; 
but  should  he  wake  after  an  hour  or  two  of  sleep, 
the  repetition  of  a  similar  dose  will  secure  a  good 
night's  rest. 

The  bromides  are  often  of  the  greatest  service, 
especially  in  the  senile  hearts  of  fe- 

JJse  of  the  ^  '^ 

bromides  as  males  about  their  climacteric.  But 
sedatives.  ^-^q  bromides  are  pure  sedatives,  and 
are  not  to  be  trusted  to  for  any  hypnotic  action. 
The  bromide  of  potassium  is  supposed  to  enfeeble 
the  heart's  action  ;  a  similar  objection  is  not  appli- 
cable either  to  the  bromide  of  ammonium  or  of 
sodium. 


CHAPTER  XII 

THE  PBOGNOSIS  OF  SPECIAL  SYMPTOMS.  RECA- 
PITULATION OF  TREATMENT,  WITH  SPECIAL 
REFERENCE  TO  SYMPTOMS 

There  is,  strictly  speaking,  only  one  possible 
prognostic  dictum  applicable  to  all  senile  hearts ; 
fortunately  a  lapse  of  many  years  often  intervenes 
between  such  a  prediction  and  its  fulfilment. 

When  prognostication  is  required  in  reference 
to  any  special  symptom,  and  its  relation  to  the 
prolongation  of  life,  the  answer  is  neither  so 
simple  nor  so  certain. 

Precordial   anxiety   often    distresses    a    patient 
greatly.     It   is   the    earliest  symptom  prognosis  in 
of    the   senile    heart   (aiitea,   p.    35),  relation  to 

.       .  symx>toms. 

and   the  prognosis  is  favourable  pro-  precordial 
vided  the  cause  is  remediable.  anxiety. 

If  the  cause  of  myocardiac  weakness  is  irre- 
mediable, or  if  a  remediable  cause  is    ^  , 

Intermission 

neglected,    and    allowed    to    continue  and 

its  evil  influence,  the  Aveakened  myo-   ^''^^duanij. 

287 


288  THE   SENILE  HEART 

cardium  speedily  comes  under  the  influence  of 
reflex  inhibition,  and  the  heart's  action  becomes 
intermittent  or  irregular.  Now,  a  man  with  an 
intermittent  or  irregular  heart  may  live  for  many 
years;  but  his  life  is  handicapped  by  his  heart,  and 
if  the  cause  of  the  myocardiac  debility  is  irre- 
mediable, or  is  carelessly  allowed  to  continue  its 
injurious  influence,  in  no  long  time  the  heart 
dilates  (antea^  p.  40),  and  the  declension  be- 
comes more  rapid.  At  any  age  an  intermittent  or 
irregular  heart  is  amenable  to  treatment,  and  may 
be  cured.  But  a  heart  dilated  after  middle  life  is, 
to  say  the  least  of  it,  only  rarely  rehabilitated ;  it 
has  taken  a  downward  step  which  is  seldom  re- 
traced. Life  is  now  more  seriously  handicapped ; 
breathlessness  and  oedema  are  not  long  in  follow- 
ing. 

Any  violent  shock  may  force  even  a  strong 
heart  to  intermit  or  become  irregular.  But  in 
such  a  heart  intermissions  die  away  in  from  six 
months  to  a  year  (antea^  p.  43).  Any  sudden 
shock  acting  on  a  feeble  heart  may  prove  imme- 
diately fatal,  or  a  less  severe  shock,  worry,  or 
anxiety  may  bring  on  intermission  and  irregularity, 
or  may  precipitate  serious  dilatation  of  the  heart, 
terminating  fatally  in  a  few  months,  anticipating 
by  more  than  a  dozen  of  years  the  natural  progress 
of  the  affection  (^antea,  p.  44). 


FROGiVOSIS   OF  SPECIAL   SYMPTOMS  289 

Palpitation  affects   the   young  rather  than  the 

old,  and  though  a  distressing  symptom, 

Palpitation. 

it   is   rarely  attended   by  any  danger 
(antea^  p.  63). 

Tremor  cordis  is  a  most  alarming  symptom  to 
the  sufferer.     It  does  occur  in  early 
adolescence,  but  rarely:  after  middle   ^^^^^^ 

•^  cordis. 

life  it  is  common  enough.  It  does  not 
seem  to  have  any  marked  injurious  influence,  and 
though,  perhaps,  not  specially  favourable  to  lon- 
gevity, any  effect  it  may  have  in  shortening  life,  or 
even  in  promoting  cardiac  dilatation,  has  not  as 
yet  been  ascertained.  Tremor  cordis  seems  to  be 
always  connected  with  gastric  disturbance,  and  is 
rarely  unaccompanied  by  some  of  the  other  phe- 
nomena of  the  senile  heart  {antea.,  p.  64). 

Tacliycardia   is    always    a   symptom   (antea^  p. 
71),  and  its  prognosis  depends  upon 

T     1        1  Tachycardia. 

its  cause.  When  tachycardia  has  been 
brought  on  by  vagus  poisoning,  as  by  alcohol, 
tobacco,  etc.,  the  prognosis  is  not  serious,  though 
there  is  considerable  temporary  risk  to  an  aged 
heart.  Reflex  tachycardia  (antea.^  p.  82)  is  in 
most  cases  readily  curable,  though  it  sometimes 
lasts  for  years,  apparently  without  any  detriment 
to  the  sufferer.  When  associated  with  inflamma- 
tory affections  of  the  myo-  or  endocardium,  the 
prognosis  must  be  very  guarded.     It  becomes  less 


290  THE   SENILE  HEART 

serious  when  the  affection  gets  localized  as  a  val- 
vulitis. The  prognosis  of  tachycardia  is  most 
serious  when  it  is  associated  with  compression  of 
vagus  by  a  tumour. 

Bradycardia.     Of  this  there  are  two  forms  :  one, 
the  gouty  variety,  depends  upon  alter- 

Bradycardia.  .  ,         .  ^-, 

natmg  hemi-systoles  (antea^  p.  92); 
and  the  other,  the  true  bradycardia  (antea^  p.  106). 
Both  varieties  are  associated  with  dilatation  of  the 
heart,  but  the  hemi-systolic  form  is  amenable  to 
treatment,  and  its  prognosis  is  that  of  an  ordinaiy 
dilated  heart,  dependent  on  the  age  of  the  patient 
and  the  condition  of  his  myocardium.  True  brady- 
cardia —  and  the  two  varieties  can  always  be  differ- 
entiated by  their  sphygmograms  —  is  a  very  serious 
affection,  and  life  seems  rarely  to  be  prolonged 
beyond  three  or  four  years,  the  end  being  pre- 
cipitated by  an  epileptic  attack.  Hemi-systolic 
bradycardiacs  are  also  exposed  to  a  similar  risk, 
but  in  them  this  risk  is  never  so  imminent,  and  it 
may  be  averted. 

Delirium  cordis  is  always  a  serious  affection.     If 

it  be  impressed  on  a  strong  heart  by 

Delirium  ^  combination  of  work  and  worry,  it 

cordis. 

may,  with  care,  continue  to  handicap 
the  sufferer  for  as  long  as  twenty  years.  As  a 
rule  it  is  most  likely  to  be  found  in  connection 
with  feeble,  dilated  hearts,  and  then  a  fourth  part 


PROGNOSIS   OF  SPECIAL   SYMPTOMS  291 

of  that  period  will  probably  cover  the  termina- 
tion. 

Angina  pectoris   affords   an   instance   in  which 
experience  enables  us  to  give  a  more 
hopeful    proo^nosis    than    professional  ^^S'*^^ 

^  ^      ^  ^  pectoris. 

oj)inion  would  at  first  be  inclined  to 
homologate.  Every  case  of  so-called  pseudo- 
angina  must  be  considered  on  its  own  merits. 
Hysterical  angina  is  of  little  importance.  In 
gouty  angina,  if  the  attacks  are  hysterical  in 
character,  it  must  come  under  that  category ;  if 
otherwise,  it  must  be  considered  as  an  ordinary 
angina.  In  every  case  of  angina  the  greater  the 
suffering  of  the  patient,  and  the  less  there  is  dis- 
coverable wrong  with  the  heart,  the  greater  the 
danger,  and  at  the  most  a  few  months  will  include 
the  termination  of  the  case.  If  the  heart  be  simply 
dilated,  treatment  may  be  of  much  service,  and  life 
may  be  prolonged  for  a  dozen  of  years.  If  the 
heart  is  already  considerably  hypertrophied  before 
the  angina  sets  in,  treatment  is  never  of  so  much 
service,  and  life  is  not  likely  to  be  so  prolonged. 

Affections  of  the  heart,  and  especially  senile 
affections  of  the  heart,  are  not  adapted  for  accu- 
rate prognosis.  In  all  of  them  the  element  of 
uncertainty  bulks  too  largely :  we  must  therefore 
carefully  refrain  from  any  too  dogmatic  assertion. 
Still,  it  is   of    consequence    to    know    the    exact 


292  THE   SENILE  HEART 

nature  and  the  probable  result  of  any  special 
symptom,  such  as  tremor  cordis;  and  though 
somewhat  wantmg  in  definiteness,  the  foregoing 
statements  may  yet  be  useful  to  many. 

Tabular  Recapitulation  of  Treatment. 

In  every  case  careful  removal  of  the  Icedentia. 
Precordial  Careful  dieting ;  cardiac  tonics  ;  rest 

anxiety.  ^t  first,  afterwards  regulated  exercise. 

Careful  dieting;  vascular  stimulants,  combined 
.   .        with   cardiac   tonics  ;   sedatives,   espe- 

Intermission  _  _     ^ 

andirregu-      cially  for  women   about  their  climac- 

larity.  teric,  occasionally  hypnotics  ;  antacids 

and  anti-arthritics ;   assafcEtida  Qpil.  galhani  co.^  ; 

moderate  exercise. 

Antacids ;  stimulants ;  mustard  over  precordial 

region ;    hot   foot-baths.      In   interval 

Palpitation.  i  •  i 

strengthen  patient  by  open-air  exer- 
cise, good  food,  and  such  tonics  as  may  seem 
needful,  especially  iron. 

Tremor  Careful  dieting  most  important ;  ant- 

cordis.  acids  ;  anti-arthritics ;  pil.  galbani  co. 

Careful  dieting;  in  recent  cases  following  car- 
diac overstrain,  belladonna,  or  atropine. 
Tachycardia.  i      i      -n  -i      ti  t 

must  be  pushed  till  pupils  dilate.  In 
cases  of  poisoning  by  tobacco  or  alcohol,  tonic 
doses  of  digitalis  useful.  Cardiac  tonics,  espe- 
cially digitalis  and  arsenic,  continued  for  a  long 


RECAPITULATION  OF   TREATMENT  293 

time  in  moderate  closes,  supplemented  by  hyp- 
notics at  bedtime,  especially  morphia.  Digitalis 
most  useful  in  vagus  paralysis,  morphia  in  affec- 
tions of  the  sympathetic.  Cholate  of  soda  slows 
the  pulse,  but  it  destroys  the  blood  corpuscles, 
and  the  benefit  is  thus  a  doubtful  one.  Antipy- 
rine  has  been  recommended  theoretically.  Faradi- 
zation of  the  skin  over  the  precordial  or  of  the 
vagus  nerve ;  or  the  skin  or  vagus  may  be  gal- 
vanized. Compression  of  the  vagus.  Forced 
inspiration,  holding  the  breath  as  long  as  possible. 
Ether  sprayed  along  the  cervical  spine.  A  chlo- 
roform poultice  over  the  precordial  region. 

In  the  hemi-systolic  variety,  cardiac  tonics,  espe- 
cially digitalis.  In  true  bradycardia 
digitalis  is  also  indispensable,  to  main- 
tain the  elastic  tonicity  of  the  heart,  and  to  en- 
able the  heart  to  cope  with  the  exceptionally  high 
blood  pressure  (antea^  p.  106)  prevalent  during 
part  of  the  systole. 

Careful  dieting,  vascular  stimulants.   Delirium 
cardiac    tonics,     antacids,    and     anti-  cordis. 
arthritics. 

During  the  paroxysm,  nitro-glycerine,  nitrite  of 
amyl,  chloroform  and  morphia.     Dur- 
ing   the    interval    most    careful    and  ^^f^^ 

°  pectoris. 

abstemious     diet,    especially    towards 

evening.    Vascular  stimulants  in  combination  with 


294  THE  SENILE  HEART 

cardiac  tonics,  especially  arsenic.  Exercise  is  to 
be  avoided,  and  only  undertaken  when  duly  pre- 
pared for  by  the  ingestion  of  some  vascular  stim- 
ulant. 

Such,  then,  is  the  armamentarium  most  useful 
in  senile  heart  troubles.  Its  constituents  are  all 
valuable  remedies,  and  though  some  of  them  are 
interchangeable,  yet  each  has  its  own  peculiar 
mission  for  which  it  is  best  adapted.  Each  case 
must  be  carefully  considered  from  every  point  of 
view,  thoroughly  individualized,  and  the  treat- 
ment best  adapted  to  attain  the  end  in  view  firmly 
laid  down  and  persistently  carried  out.  A  disease 
that  has  been  gradually  coming  on  for  thirty  or 
forty  years  cannot  be  expected  to  yield  to  a  week 
or  two  of  treatment,  however  skilfully  devised  or 
carefully  carried  out.  It  often  takes  many  months 
of  care  before  an  irregular  heart  is  made  regular, 
or  the  declension  of  a  failing  heart  is  arrested.  In 
time,  however,  all  this  can  be  done.  Time,  how- 
ever, is  required ;  for  it  is  not  to  be  done  by  any 
dexterous  legerdemain,  but  by  the  skilful  imita- 
tion of  natural  processes,  and  by  the  steady  accu- 
mulation of  trifling  advantages ;  and  our  drugs 
must  be  mixed  like  Opie's  colours  —  with  brains. 


IInTDEX 


Aconite,  action  of,  81. 
Action,  idio-ventricular,  39. 
irregular,  of  heart,  how  pro- 
duced, 40,  48. 
irregular,  of  heart,  danger  of, 
40. 
Adipositas  cordis,  251. 
Age,  the  result  of  tissue  change, 
not  of  years,  19. 
alteration  in  arterial  system 

due  to,  13. 
typical  death  from,  18. 
Alcohol  unsafe  for  aged  hearts, 

243. 
Amyl,  nitrite  of,  276. 

nitrite     of,      an     analgesic, 
276. 
Anabolic  nerve  of  heart,  39. 
Anaemia,     a     source     of    heart 

trouble,  29. 
Anaesthetics,  282. 
Analgesic,  the  only  real,  281. 
Angina  jpectoris,  115. 

may  occur  in  early  life,  116. 
syndrome  of,  121. 
prognosis  in,  141,  291. 
cause  of,  125. 
Angina,  vaso-motoria,  131. 
Antacids,  278. 
Anti-arthritics,  278. 
Anxiety,  precordial,  35. 
Aortic  second,  accentuation  of, 
35. 
accentuation  of,  what  it  indi- 
cates, 57. 


Aortic  second,  a  booming,  57. 
regurgitation,  how  produced, 

57. 
systolic  murmur,  58. 
systolic  murmur  precedes  re- 
gurgitation, 58. 
Arrest  of  heart's  action,  volun- 
tary, 67. 
Arsenic  as  a  cardiac  tonic,  270. 
use  of,  by  Styrians,  270. 
use  of,  may  be  continued  for 
years,  272. 
Arterial  system  first  to  fail,  19. 
Arteries  of  the  young  may  be 

rigid,  229. 
Arterio-capillary  fibrosis,  200. 
Arthritis,  rheumatoid,  181. 
Asthenia,  ingravescent,  29. 
Atherosis,  205. 
Asthma,  cardiac,  135. 

death  from,  137. 
Asystole  may  be  sudden  or  in- 
gravescent, 80. 
case  of  ingravescent,  139. 
Augmentor      and      accelerator 

nerves,  37. 
Auricular  murmur,  its  position 
and  cause,  55, 
why  not  always  to  be  heard, 
55. 
Auscultation  a  means  of  detect- 
ing cardiac  dilatation,  53. 


Balfour,  W.,  his    treatment  of 
gout  by  massage,  172. 


296 


296 


THE   SENILE  HEART 


Bile,   the    mere    draiuage   of    a 
manufactory,  187. 

amount  of,  in  man,  188. 

free  secretion  of,  relieves  the 
heart,  189. 
Bismuth,  279. 
Blood  pressure,  what  it  is,  273. 

in  youth,  11. 

rises  when  growth  ends,  12. 

changes  in,  from  age,  14. 

an  increase  of,   embarrasses 
the  heart's  action,  273. 

increased,  tends  to  dilate  the 
heart,  60. 

a  healthy  heart  successfully 
copes  with,  25. 

lowering  the,  relieves  a  weak 
heart,  274. 

effects  of  high,  intra-pulmo- 
nary,  159. 

effects   of  low,  intra-pulmo- 
nary,  100. 

effects  of  vascular   environ- 
ment on,  27. 

lowered    by  vascular  stimu- 
lants, 275. 

lowered    by    cholagogue    ca- 
thartics, 279. 

indications,  diagnostic   from 
high,  226. 

indications,   diagnostic   from 
low,  225. 

effects    of,  on    arterial    ten- 
sion, 228. 
Bradycardia,  51,  93. 

hemi-systolic,  92. 

hemi-systolic,  case  of,  92. 

prognosis  of,  290. 

true,  107. 

Holberton's  case  of,  99. 

case  of,  109. 

Bromides  as  sedatives,  28G. 
Bulimia,  gouty,  186. 

Capillaries,   phenomena   due    to 
obsolescence  of,  14. 


Cardiac   movements  primordial 
in  character,  36. 

influence  of  nervous  system 
on,  37. 

irritability,  220. 
Case  of  dilatation  of  heart,  42. 

gouty  glycosuria,  191. 

supposed  fatty  heart,  216. 

Colonel  Townsend,  67. 

illustrative  of  angina,  145. 

angina  in  young  woman,  122. 

ingravescent  asystole,  139. 

irregular  heart,  46. 

tachycardia,  78. 

bradycardia,  92,  93,  99,  109. 
Cathartics     cholagogue,     lower 

blood  pressure,  279. 
Cervical  cord,   injury    to,    pro- 
duces bradycardia,  98. 
Chloral,  hydrate  of,  282. 
Chloralamid,  284. 
Chloralose,  285. 
Chloroform,  282. 
Circulation,  condition  of,  up  to 

middle  life,  11. 
Colchicum,    use    of,    in    senile 

heart,  278. 
Cornaro,  Luigi,  253. 

his  diet,  254. 
Cullen's  definition  of  gout,  163. 

Death,  rarely  due  to  age  alone,  1. 

defined,  9. 

sudden,  from  emotion,  31. 

from  angina,  138,  139. 

from  age,  typical,  18. 
Decay,  premature,  5. 

final  stage  of  development,  4. 
Delirium  cordis,  113. 

prognosis  in,  290. 
Deposits    of    urates    in    gouty 

joints,  164. 
Depressor  nerve  of  heart,  38. 
Development    ends    only    with 
death,  4. 

may  be  precocious,  4. 


INDEX 


297 


Developmental  phenomena  may 
be  terminal  as  well  as  in- 
itial, i. 
Diathesis,  gouty,  161. 
Diet,  dry,  252. 

Cornaro's,  254. 
Dietaries,  237. 
Dietetic  regulations,  238. 
Digitalis,  use  of,  260. 
accumulation  of,  259. 
accumulation,  how  to  avoid, 

261. 
object  and  mode  of  using,  263. 
must  be  combined  with  vas- 
cular stimulants,  266. 
Dilatation  of  heart,  time  required 
to  produce,  44. 
effect  of,  in  displacing  apex- 
beat,  53. 

Emotion,   intensity    of,   an    im- 
portant factor,  45. 
may  prove  suddenly  fatal,  31. 
fruitful      source     of     heart 
trouble,  31. 
Epilepsy,  character  of  attack  in 

bradycardia,  104. 
Excess  in  food  more  dangerous 

than  in  drink,  236. 
Exercise,  232. 

Exertion,   effect  of,   on   an  an- 
semic  pulse,  47. 
danger  of  unduly  prolonged, 
to  the  heart,  30. 

Fakeers,  Indian,  how  they  slow 

the  heart,  68. 
Fasting  men,  253. 
Flatulence,   disturbs   the    heart 

directly,  280. 
disturbs   the   heart    reflexly, 

280. 
Force,  vital,  what  it  is,  9. 

cause  of  failure  of  genesis,  10. 
Fothergill's  case    of    voluntary 

slowing  of  heart,  67. 


Fermentation  test  not  devoid  of 

fallacy,  190. 
Fluids    must    be    restricted    at 

meal  times,  243. 
less  injurious  between  meals, 

244. 

Giants,what  tliey  are,  12  (note). 
Graves'  disease,  syndrome  of,  71. 
Glycosuria,  gouty,  191. 

cause  of,  195. 
Glycuronic  acid  decomposes  cop- 
per in  Fehling's  test,  190. 
Gout,  Cullen's  definition  of,  163. 
in  no  respect  inflammatory, 

164. 
resolution    of    paroxysm    al- 
ways incomplete,  164. 
temperature  of  affected  joint, 

164. 
Balfour,  W.,    his    treatment 

of,  172. 
Sir    W.   Temple's    treatment 

of,  170. 
The  Ehyngrave's    treatment 

of,  171. 
massage  in  the  treatment  of, 
170. 
Gouty  diathesis,  what  it  is,  161. 

present  in  every  one,  162. 
Gouty  paroxysm  a  mere  episode 
in  its  history,  163. 
history  of  a,  165. 
due  to  infarction,  166. 
Growth,  influence  of  heredity  in 
causing   cessation    of,    13 
(note) . 
precocious,  not  identical  with 
premature  development,  5 
(note) . 
conditions  of,  in  early  life,  11. 

Haemogenesis,' interference  with, 

224. 
Haemolysis,  causes  of,  226. 
Heart  always  hypertrophied  in 

the  old,  22. 


298 


THE   SENILE  HEART 


Heart,  changes  in,  from  age,  22. 

sources  of  vigour  in  the 
senile,  25. 

cause  of  trouble  in  the  senile, 
27. 

changes  in,  when  dilated,  52. 

idiopathic  enlargement  of,  89. 

gouty  heart,  34, 

nervous,  34. 

innervation  of,  37. 

inhibition  of,  43. 

inhibition  of,  favours  dilata- 
tion, 43. 

proportion  of  senile,  to  or- 
dinary heart  affections, 
143. 

proportion  of  anginas  among 
senile  hearts,  144. 

proportion  of  anginas  among 
males  and  females,  144. 

proportion  of  anginas  cured, 
144. 

essential  lesion  of  the  senile, 
33. 

symptoms  of  the  senile,  35. 

troubles  of  the,  always  alarm- 
ing, 214. 

troubles  rarely  arise  from 
failure  of  the  trophic 
nerves,  215. 

troubles  may  be  remedied  at 
any  age,  216. 

fatty,  diagnosis  of,  249. 

supposed  fatty,  generally  only 
weak,  250. 

irritable,  217. 

affections  often  last  long,  219. 
Hemi-systolic  bradycardia,  92. 
Hyalin  fibroid  disease,  200. 
Hyperdicrotism   in   tachycardia 
indicates  danger,  79. 

Infarction,  what  it  is,  166. 

cause  of  gouty  jiaroxysm,  166. 
Inhibition  of  heart,  43. 

favours  dilatation,  43. 


Interference,  vagus,  the  cause  of 

irregularity,  48. 
Irregular    cardiac    action,    case 
of,  46. 
causes  of,  48.  ^ 
diminishes  efficacy  of  heart 

beat,  41. 
danger  of,  40. 
is  never  unimportant,  41. 
prognosis  in,  287. 
Ischsemia,  cardiac,  its  relation  to 
angina,  126. 
causes  of,  126. 
cause  of  pain  in  angina,  131. 

Jenner,  Edward,  first  to  point 
out  that  ischsemia  was  the 
cause  of  pain  in  angina, 
130. 

Katabolic    nerve,    the,    of    the 

heart,  38. 
Kidney,  relations  of,  to  heart, 
196. 
Bright's  idea  of,  197. 
Traube's  idea  of,  197. 
George  Johnson's  idea  of,  198. 
Gull  and  Sutton's  idea  of,  200. 
the  red,  contracting,  196. 
the  senile,  202. 
the  senile,  a  true  gouty,  202. 
the  gouty,  preventable,  202. 
Knobs,  Heberden's,  178. 
Kreatin,  and  kreatinic  acid,  de- 
compose  copper   in   Feh- 
ling's  solution,  190. 

Life  defined,  8. 

form  of  energy,  7. 
"  Luxus  "  heart,  the,  34. 

not  due  to  overfeeding  alone, 
227. 

Massage,  treatment  of  gouty 
paroxysm  by,  170. 

Metabolism,  danger  of  imper- 
fect, 223. 


INDEX 


299 


Morphia,  uses  of,  281. 
Muscles,  twittering  of  the,  183. 
Myocardium,  weakness  of  the, 
its  symptoms,  33. 
failure  of  the,  220. 
failure  of  the,  treatment  of, 
231. 

Nails,  ridged,  177. 

furrowed,  177. 
Narcotics,    danger    of,    to    the 
senile  heart,  257. 

use  of,  281. 
Nitrite  of  sodium,  275. 
Nitrites,  action  of,  275. 
Nitro-glycerine,  277. 
Nodosities,  Haygarth's,  180. 
NiL%  vomica  as  a  heart  tonic,  268. 

Obesity,  how  to  reduce,  248. 
Overwork,  effect  of,  on  heart,  30. 

Pain,  cause  of,  in  gout,  168. 
Palpation  of  heart,  52. 
Palj)itation,  63. 

prognosis  of,  289. 
Paraldehyde  as  a  hypnotic,  284. 
Percussion  of  heart,  52. 
Plethora,  30. 
Poisons,  various,  slow  the  heart, 

105. 
Precordial  anxiety,  35. 

prognosis  of,  287. 
Precordial     pains    not    always 
anginous,  116. 

many  varieties  of,  117. 
Prognosis   in   heart    affections, 

287. 
Puberty,  cause  of  (note),  12. 
Pulse  and  blood  require  atten- 
tion, 224. 

during  tremor  cordis,  65. 

in  tachycardia,  69. 

in  Graves'  diseases,  71. 

in  palpitation,  63. 

normal,  sometimes  unusually 
slow,  96. 


Raynaud's  disease  (note),  85. 

Regurgitation,        aortic,        how 
brought  about,  57. 
ventricular,  Krehl's  account 
of  it,  60. 

Remora  of  serous  plasma  in 
inter-vascular  spaces,  27. 

Rest,  importance  of,  in  treat- 
ment of  senile  heart, 
234. 

Rhyngrave,  the,  his  cure  for 
gout,  171. 

Sclerosis,  coronary,  its  relation 

to  angina,  125. 
Scott,  Sir  W.,  on  tremor  cordis, 

66. 
Senile  degeneration  of  the  heart 

from    the    morbid   anato- 
mist's point  of  view,  32. 
Soda  as  antacid,  278. 
Sound,  booming  first,  what    it 

signifies,  54. 
a  booming    second,  what    it 

signifies,  57. 
Sounds    of    heart,    progressive 

alteration  of,  as  dilatation 

proceeds,  54. 
Spa    treatment,    danger    of,    in 

senile  heart,  251. 
Spinal  accessory,  compression  of, 

slows  heart,  102. 
Sphygmogram    of  hemi-systolic 

bradycardia,  106. 
of  true  bradycardia,  107. 
of  feeble  and  irregular  pulse, 

46. 
of  irregular  pulses  in  dilated 

hearts,  47. 
of  pulse  of  tachycardia,  78. 
Stimulant,  hot  water  the   best 

cardiac,  244. 
Stimulants,  vascular,  their  use, 

266. 
drugs  that  are,  275. 
Strophanthus,  use  of,  267. 


300 


THE   SENILE  HEART 


Strychnine  as  a  heart  tonic,  268. 
Sympathetic,    the    katabolic 

nerve  of  the  heart,  38. 
Symptoms,   objective,  of  senile 

heart  most  reliable,  221. 
Syndrome  of  Graves'  diseases,  71. 
of  tachycardia,  71. 
of  true  angina,  121. 
Systole  shortened  in  tachycardia, 

79. 

Tachycardia,   or    heart    hurry, 
69. 
prognosis  of,  289. 
treatment  of,  292. 
physiological,  70. 
pathological,  72. 
from  poisoning,  75. 
reflex,  82. 
action  of   augmentor   nerve 

in,  83. 
often     accompanies     mitral 

stenosis,  71. 
sometimes  emotional,  85. 
two  cases  of ,  85. 
Tea,  tobacco,  etc.,  as  causes  of 

angina,  127. 
Temperance    in    all    things  im- 
portant    preservative     of 
cardiac  health,  236. 
Temple,   Sir  W.,  on  the  treat- 
ment of  gout,  170. 
Tissues  condense  with  age,  16. 
Tithonus  a  typical  aged  man,  16. 

dies  in  real  life,  17. 
Thrombosis  of  veins  common  in 
gout,  167. 


Thrombosis,     source     of    many 

accidents  in  gout,  173. 
Tobacco,  use  of,  254. 

dangerous  in  senile  heart,  255. 
Townsend,  case  of  Colonel,  67. 
Tremor  cordis,  64. 

often  arises  from  flatulence, 

68. 
is  never  emotional,  68. 
prognosis  in,  289. 
sudden  onset  of,  65. 
treatment  of,  292. 
Treatment   of    myocardiac  fail- 
ure, 231. 
of  various  cardiac  symptoms, 
292. 
Turgescence,    red,   in    gout,  its 
cause,  168. 

Uric  acid  decomposes  copper  of 
Fehling's  test,  190. 

Vagus,  the  anabolic  nerve  of  the 
heart,  39. 
compression      of,     produces 
tachycardia,  90. 

Vascular  stimulants,  action  of, 
275. 
must  be  combined  with  car- 
diac   tonics     in    treating 
senile  heart,  266. 

Venosity  of  blood,  cause  of,  160. 

Vichy  water  as  an  antacid,  278. 

Water,  hot,  sipping,  the  best 
stimulant  for  the  heart, 
244. 


I 


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